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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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Pierce college summer boot camp

Pierce College

Summer Boot Camp

Diabetes:Part 1. ReviewPart 2. Assessment





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

Type 2 becomes more common with age




Type 2 diabetes becoming increasingly common

Type 2 diabetes becoming increasingly common


Type 2 symptoms develop gradually

  • Onset is NOT sudden older adults

  • 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: older adults

    • 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 older adults

  • 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


Microvascular changes
Microvascular changes older adults


Manifestations of microvascular disease in diabetes 1

Diabetic older adults

retinopathy

Manifestations of microvascular disease in diabetes 1



Manifestations of microvascular disease in diabetes 2

Diabetic older adults

nephropathy

Manifestations of microvascular disease in diabetes 2


Manifestations of microvascular disease in diabetes 3

Diabetic older adults

neuropathy

Manifestations of microvascular disease in diabetes 3


Effects of diabetic neuropathy

  • Paresthesias older adults

  • Loss of sense of touch, vibration, proprioception, temperature

  • Blunted perception of foot trauma

  • Carpal tunnel

  • Cranial neuropathies:

    • Diplopia

    • Ptosis

    • Anisocoria

Effects of diabetic neuropathy


Macrovascular changes

Complications develop due to atherosclerotic changes older adults

Macrovascular changes


Diabetic macrovascular disease

  • Angina pectoris older adults

  • 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

Diabetes treatment goals



Education

  • Causes older adults

  • 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 older adults

  • 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 older adults

Glipizide

Glyburide

Glimeperide

Meglitinides

Prandin

Starlix

Cause pancreas to release more insulin


Improve ability to move glucose into the cell esp muscle cells

Biguanides older adults

Metformin

Should not be used in patients with kidney

damage

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


Lower amount of sugar released by liver

Pioglitazone ( older adultsActose)

Rosiglitazone (Avandia)

Lower amount of sugar released by liver



Medical history

What is the patient’s age? older adults

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? older adults

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? older adults

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? older adults

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? older adults

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? disorders?

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 disorders?

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 disorders?

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 disorders? examination

Why:

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

Physical examination



Physical examination3

Thyroid palpation disorders?

Why:

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

Physical examination


Thyroid palpation
Thyroid palpation disorders?


Physical examination4

Skin assessment disorders?

Why:

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

Increased glucose in the blood predisposes to skin infections.

Physical examination


Sclerederma diabeticorum
Sclerederma disorders?diabeticorum


Vitiligo
Vitiligo disorders?


Acanthosis nigricans
Acanthosis disorders?nigricans


Physical examination5

Foot exam: disorders?

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


Monofilament exam
Monofilament exam disorders?


Physical examination6

Patellar and Achilles reflexes annually disorders?

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 disorders?

Why:

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

Physical examination


Physical examination8

Respiratory assessment disorders?

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 disorders?

Why:

Microvascular disease causes nerve ischemia and results in diabetic neuropathy.

Full assessment of cranial nerves and sensation should be performed.

Physical examination


Review of lab values

At minimum… disorders?

Review of lab values


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