Diabetes Mellitus Type I

ASSESSMENT
1. 1. 3 P's
    1. Polyuria
    2. Polyphagia
    3. Polydipsia
  2. Weight Loss
  3. Weakness
  4. Fatigue
  5. Glycosuria
2. Risk Factors
  1. Genetics
  2. Environment
3. Complications
  1. Acute
    1. Diabetic Ketaoacidosis (DKA)
      1. Caused by profound deficiency of insulin
        results in severe metabolic, fluid and electrolyte disturbances
        life-threatening condition of hyperglycaemia and metabolic acidosis
    2. Hypoglycemia
      1. low blood glucose
    3. Complications Due to Diabetic Control
      1. Somogyi Effect
        - rebound effect in which an overdose of insulin causes hypoglycemia due to release of counterregulatory hormones - hypoglycaemic episode tends to occur during the night (during hours of sleep) or at a time when it is not recognized
        low blood glucose
      2. Dawn Phenomenon
        - characterized by a hyperglycaemic episode due to release of counterregulatory hormones (increased levels of fasting blood glucose, or insulin requirements, or both without antecedent hypoglycaemia) - tends to occur during the predawn hours (5 AM - 9 AM) or when the individual wakes up - possible factors for occurrence: - growth hormone/cortisol possible factors
  2. Chronic
    1. Immune System
      1. impaired healing; chronic skin infections; periodontal disease; urinary tract infections; lung infections and et cetera
    2. 1. Ingtegumentary Complications
      2. Microvascular Angiopathy
      3. Macrovascular Angiopathy
4. Nursing Assessments
  1. Symptom analysis, fluid status, I&O, nutritional status, weight, energy level, GI symptoms, neurological assessment, history of recent infections or difficulty healing
DIAGNOSIS
1. Diagnostic Tests
  1. Urine Tests
    1. postive for presence of glucose, ketones and proteins
  2. 1. Fasting Plasma Glucose (FPG)
      1. ≥ 7 mmol/L
    2. Casual Blood Glucose Test
      1. ≥11 mmol/L plus classic symptoms
    3. Oral Glucose Tolerance Test (OGTT)
      1. ≥11.1 mmol/L when a glucose load of 75 g is used
    4. Glycosylated Hemoglobin (A1C)
      1. CDA ≤7.0% ; Normal range is <6.0%
2. Nursing Diagnosis
PLANNING
1. Overall Goals
  1. Active patient participation
  2. Maintain normal glucose level (b/t 4.0-6.0mmol/L)
  3. Prevent or delay chronic complications
  4. Lifestyle adjustments with minimal stress
  5. Few/no episodes of acute hyperglycemic/hypoglycemia emergencies
EVALUATION
1. Expected patient outcomes may include the following:
IMPLEMENTATION
1. Acute interventaion
  1. Hypoglycemia
    1. Patient Alert To Swallow
      1. 15 to 20 g of a simple carbohydrate or 175 mL of fruit juice or Regular soft drink
    2. Patient Not Alert To Swallow
      1. Administer 1 mg of glucagon IM or subcutaneously
  2. DKA
    1. Administer continuous low-dose short acting insulin infusion after initial dose of insulin
    2. Monitor: BG hourly, electrolytes every 2hours after start of IV therapy, hourly fluid input and output
  3. Stress of illness and surgery
    1. Frequent monitor BG level, ketone testing if glucose >14 mmol/L, continue with insulin therapy, regular meal plan - increase intake of non-caloric fluids
2. chronic intervention
  1. Smoking Cessation
  2. Lifestyle changes
    1. control blood lipids, HTN, BG
  3. Drug therapy
    1. antiplatelet agents (ex. aspirin or clopidogrel
3. General treatments
  1. Drug therapy
    1. Insulin Injections
      1. Bolus
        Lispro, Aspart, Glulisine
      2. Basal
        NPH
        glargine
      3. Choice of insulin depends on many factors: Age , Duration of DM ,Family lifestyle, Socioeconomic factors ,Family, patient, & physician preferences
      4. at bed time or in the morning, CAN NOT be mixed with other insulin or solution
    2. Insulin pump
      1. continuous subcutanous infusion
      2. continuous glucose monitor
  2. Nutrition
    1. Canadian diabetes association [CDA] - provides variety of nutrition teaching tools
      1. Alcohol
        no benefit at all, high in calories
        *Promote hypertriglyceridemia, sever hygolycemia
      2. reduce saturated fats & trans fats to <7% of energy intake
        foods rich in polyunsaturated omega 3 fatty acids and plant oils
      3. Proteins: Limit to 15% of total energy intake
      4. carbs counting
        <10% daily energy should come from sugar
      5. counselling from a Registered dietitian
      6. Children/adolescents: normal growth & development should be considered
    2. balance is essential
  3. Exercise
    1. Essential part of management
      1. insulin receptor sites, glucose level, carbs snacks (every 30min during exercise to prevent hypolgycemia), weight loss
    2. after meal, personalized plan, start slowly with gradual progression
4. Health Promotion
  1. Family & patient education
    1. Teach insulin administration
      1. subcutaneous injection. self administration abdomen is preferred site. Abdoment > arm>thigh>buttock
        Rotate injections
        do not inject in site to be exercised
    2. Teach signs and symptoms of hypoglycaemia & hyperglycaemia
    3. Teach self-monitoring of glucose
    4. Teach proper diabetic foot care, need for proper shoe fit and wound care
    5. Teach what to do for sick days: maintain/increase insulin when common sickness occurs such as a cold and monitor glucose more often than usual + maintain appropriate fluid intake
  2. Screening
    1. To Test/Screen for Diabetes
      1. Testing/Screening for diabetes should be considered for the following: - individuals 45 years of age and older - obese - 1st-degree relative w/ diabetes - members of a high-risk group - have hypertension or hyperlipidemia - met the criteria (IFG, IGT, elevated AIC) for increased risked of diabetes on previous testing
    2. For Those Already Diagnosed with Diabetes
      1. dyslipidemia at diagnosis.
      2. dilated eye examinations
      3. microalbuminuria in urine; serum creatinine
DEFINITION
1. the destruction of pancreatic beta cells that leads to insulin dependence
  1. Etiology & Pathophysiology
    1. Type 1A -- Immune Mediated Diabetes (aka "Juvenile-onset")
      1. thought to be a result from the interaction of: (1) genetic predisposition -- HLA (human leukocyte antigens) (2) environmental trigger (3) T-cell mediated hypersensitivity reaction against beta cell antigens
    2. Type1B -- Idiopathic Diabetes
      1. beta cell destruction in which no evidence of autoimmunity is present - strongly inherited
    3. 1. Hyperglycaemia
        excess of glucose in the bloodstream,
        Microvascular Angiopathy
        - results from thickening of vessel membranes in capillaries and arterioles due to chronic hyperglycaemia
        Microvascular Angiopathy
        - diseases of large and medium-sized blood vessels promoted by altered lipid metabolism
  2. Risk Factors
    1. Autoimmune
    2. Viral
  3. Clinical Manifestations

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Diabetes Mellitus Type I

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	Created by Karla Co over 7 years ago