Type 1 Diabetes

Characterized by the destruction of pancreatic beta cells
1. Genetic
  1. Human leukocyte antigen (HLA) types
    1. HLA DR3
    2. HLA DR4
2. Environmental
  1. Viruses
  2. Toxins
3. Immunological
  1. Antibodies against islet cells & endogenous insulin
Clinical manifestations
1. Polyuria
2. Polydipsia
3. Polyphagia
Assessment & diagnostic findings
1. Fasting plasma glucose level (FPG)
  1. 7.0 mmol/L or more
2. A1C lab test
  1. Normal A1C level is below 5.7 percent
5 components of diabetes management
1. Nutrition
2. Exercise
3. Education
  1. 2 main types
    1. "Survival skills"
    2. In-depth, advanced continuing education
4. Monitoring
  1. SMBG 4x daily
    1. Before meals
    2. At bedtime
  2. Urine testing for ketones
    1. If glucosuria present
    2. During illness
    3. In pregnancy
    4. Persistently elevated glucose levels
5. Pharmacologic therapy
  1. Insulin therapy
    1. Conventional regimen
      1. Terminally ill
      2. Frail older adult w/ limited self-care capabilities
      3. Patients unwilling to engage in self-management activities
    2. Intensive regimen
      1. Allows for more control over blood glucose levels
      2. Ineligible candidates
        Nervous system disorders rendering them unaware of hypoglycemia episodes
        Reoccurring severe hypoglycemia
        Irreversible diabetic complications
        Blindness
        ESRD
        Cerebrovascular and/or cardiovascular disease
        Ineffective self-care skills
Patient characteristics
1. Onset any age, but usually young (younger than 30)
2. Usually thin at diagnosis
Complications
1. Acute
  1. Hypoglycemia (insulin reactions)
    1. Causes
      1. Too much insulin
      2. Too many hypoglycemic agents
      3. Too little food
      4. Excessive physical activity
    2. Description
      1. Blood glucose falls to <2.7-3.3 mmol/L
    3. Clinical manifestations
      1. Mild hypoglycemia
        Sweating
        Tremor
        Tachycardia
        Palpitation
        Nervousness
        Hunger
      2. Moderate hypoglycemia
        Headache
        Inability to concentrate
        Light-headedness
        Confusion
        Memory lapses
        Slurred speech
        Numbness of lips & tongue
        Combative behaviour
        Impaired coordination
        Emotional changes
        Double vision
        Drowsiness
      3. Severe hypoglycemia
        Disoriented behaviour
        Seizures
        Loss of consciousness
        Difficulty arousing from sleep
    4. Treatment/interventions
      1. 15g of fast-acting concentrated source of carbohydrate
        If unconscious/cannot swallow
        1mg glucagon administered subcutaneously
  2. Diabetic ketoacidosis
    1. Cause
      1. Absence or markedly inadequate amount of insulin
        Decreased or missed dose
        Illness or infection
        Undiagnosed/untreated diabetes
    2. Main clinical features
      1. Hyperglycemia
      2. Dehydration & electrolyte loss
      3. Acidosis
    3. Signs & symptoms
      1. Polyuria
      2. Polydipsia
      3. Blurred vision
      4. Weakness
      5. Headache
      6. Orthostatic hypotension
      7. Weak, thready pulse
      8. GI symptoms
        Anorexia
        Nausea
        Abdominal pain
        Vomiting
      9. Kussmaul respirations
        Low pCO2 level
        10-30 mm Hg
      10. Lethargy
    4. Diagnostic findings
      1. Low serum bicarbonate
        0-15 mmol/L
      2. Low pH
        6.8-7.3
    5. Prevention
      1. Teach "sick day" rules
    6. Medical management
      1. Fluid resuscitation
      2. Avoidance of hypokalemia
      3. Insulin administration
      4. Avoidance of rapidly falling serum osmolality
      5. Search for cause
  3. Hyperglycemic hyperosmolar nonketotic syndrome
    1. Not common in type I diabetes
2. Chronic
  1. Microvascular disease
    1. Coronary artery disease
    2. Peripheral vascular disease
    3. Cerebrovascular disease
  2. Microvascular disease
    1. Retina
    2. Kidneys
  3. Neuropathy
    1. Peripheral (sensorimotor) nerves
    2. Autonomic nerves
    3. Spinal nerves
  4. Retinopathy
  5. Nephropathy
Foot & leg problems
1. Neuropathy
2. Peripheral vascular disease
3. Immunocompromise

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Type 1 Diabetes

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