Diabetes mellitus ppt

Diabetes mellitus

1. D I A B E TE S ME LL I T U S P RE S E N T E D B Y MR. ROMAN BAJRANG RE LI A N C E IN ST I T U T E O F NURSING

2. D I A B E T E S M ELL I TU S Diabetes Mellitus is a heterogeneous group of disorder characterized by glucose intolerance. It is a disease caused by an imbalance between insulin supply and insulin demand. In Diabetes Mellitus, either there is not enough insulin or the insulin that is produced is ineffective resulting in high blood glucose levels. Diabetes Mellitus also causes disturbances of protein and fat metabolism. These abnormalities are associated with micro vascular, macro vascular and neuropathic changes. INTRODUCTION :-

3. Diabetes is a lifelong(chronic) disease and is a group of metabolic disorder characterized by high levels of sugar in blood(hyperglycemia).It is caused due to deficiency of insulin or resistance to insulin or both. Insulin is secreted by β -cells of pancreas to control blood sugar levels. • “Diabetes” comes from the Greek word for “siphon” and implies that a lot of urine is made. • The second term “mellitus” comes from the Latin word, “ mel ” which means “honey” and was used because the urine was sweet. • The term diabetes mellitus describes a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.

4. DEEFINATION According to Phipps, Monahan textbook of Medical Surgical Nursing: “Diabetes mellitus is a group of metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion action orboth.” According to lumen textbook of medical Surgical Nursing:- “Diabetes Mellitus is a heterogeneous group of disorder characterized by glucose intolerance. It is a disease caused by an imbalance between insulin supply and insulin demand”. According to Brunner and Suddharth:- “Diabetes Mellitus is a group of metabolic disease characterized by increased level of glucose in the blood (hyperglycemia) resulting, insulin action or both”.

5. INCIDENCE Appropriate 12 to 14 million Americans have diabetes and approximately 6 million of these are diagnosed About 600,000 new cases of diabetes are reported in the united states each year. Diabetes, with its complications is the fourth leading causes of death by disease in the United States. 1, 60,000 clients will die from diabetes mellitus and its complication this year. Even when diabetes does not kill, it can produce major permanent disabilities. In the United States, primarily because of the widespread cardiovascular effect that results in atherosclerosis, coronary artery disease and stroke people with diabetes are two to four times more likely to have a stroke them people who do not have diabetes. Diabetes is the leading cause of end stage renal disease.

6. ANATOMY & PHYSIOLOGY PANCREAS:- The pancreas is a retroperitoneal gland that is about :- 12 to 15 cm. long 2.5 cm thick, Weight 80 gm . Pancreas divided in to three part :- Head 30% Body Tail 70% lies posterior to the greater curvature of the stomach. The pancreas is consist of head, body, and tail and is usually connected to the duodenum by two ducts. Pancreatic juice is secreted by exocrine cell into small duct that ultimately unite to form two larger ducts : The pancreatic duct and The assessor duct. The pancreatic duct is the larger of two ducts. In most people, the pancreatic duct join the common bile duct from the liver and gallbladder and enters the duodenum as a dilated common duct called hepatopancreatic ampulla .

7. The pancreas is made up small clusters of glandular epithelial cells. About 99% of the clusters, called acini and the remaining 1% of the cluster, called pancreatic islet (islet of langerhans), form endocrine portion of pancreas, these cells are secrete the hormones: α cells – glucagon β cell -- insulin δ cell -- somatostatin Ƒ cell – pancreatic polypeptide. Each day pancreas produce 1200 to 1500ml of pancreatic juice, a clear colorless liquid consisting mostly water, some salt, sodium bicarbonate gives pancreatic juice a slightly alkaline Ph7.1-8.2

8. TYPES OF DIABETES MELLITUS There are three main types of diabetes mellitus: Type 1 DM Type 2 DM Gestational Diabetes Other types of diabetes mellitus; Maturity onset diabetes of the young 2.Neonatal diabetes

9. 1.Type 1 DM : It is due to insulin deficiency and is formerly known as- Type 1 Insulin dependent DM (IDDM) Juvenile onset DM It is due to pancreatic islet β -cell destruction predominantly by an autoimmune process. Usually develops in childhood or early adulthood. It accounts for 10% of all DM cases. Develops as a result of the exposure of a genetically susceptible individual to an environmental agent.

10. Insulin dependent diabetes mellitus (type 1 diabetes m e lli tu s ) : - It is the result of destruction of the beta cell of the islet of langerhans in the pancreas, the only cell in the body that makes insulin. Where beta cell destroyed, insulin is no longer produced. Although type 1 diabetes mellitus may be classified as either an autoimmune or idiopathic disorder, it cause the body to develop islet cell antibiotic and anti insulin anti bodies, these antibodies attack the beta cell of the pancreas and also the insulin molecule themselves. Non Insulin dependent diabetes mellitus (type 2 diabetes mellitus):- Virus and human leukocyte antigen do not appear to play a role in the development of non insulin dependents diabetes mellitus. Heredity and obesity is one of the most important determinants for the development of non insulin dependent diabetes mellitus.

11. 2. Type 2 DM: It is a combined insulin resistance and relative deficiency in insulin secretion and is frequently known as- Type 2 Noninsulin Dependent DM (NIDDM) Adult onset DM It results from insulin resistance with a defect in compensatory insulin secretion. Insulin maybe low, normal or high. About 30% of the type 2 DM patients are undiagnosed (they do not know they have the disease) because symptoms are mild. It accounts for up to 90% of all DM cases.

12. 3.Gestational Diabetes Mellitus: Gestational diabetes only happens during pregnancy. It means having high blood sugar levels, but those levels were normal before pregnancy. Despite having it one can still a healthy baby with help from her doctor and by doing things to manage her blood sugar. After baby is born, gestational diabetes usually goes away. Gestational diabetes more likely to develop type 2 diabetes, but it won’t definitely happen .

13. Diabetes Mellitus is a group of metabolic disease characterized by hyperglycemia resulting from defect in insulin secretion, insulin action as both. The basis of the abnormalities in carbohydrate, protein and fat metabolism in diabetes is the deficient action of insulin on the target tissues of skeletal muscle, adipose tissue and the liver, uncontrolled diabetes mellitus may result in long term damage, dysfunction and failure of various organ. Diabetes cannot be cured, but it can be controlled.

14. Diabetes Mellitus is a common chronic disease of adult required continuing medical supervision and client self-care education; however, depending on the type of diabetes and the age of the client, both client needs and nursing care may vary greatly. “Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose. This lead to hyperglycemia, which may result in acute metabolic complications such as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmlar non ketotic syndrome (HHNS).

15. 4.OTHER TYPES OF DM Maturity onset Diabetes of the Young (MODY):-MODY is a rare form of diabetes , which is different from both Type 1 and Type 2 diabetes, and runs strongly in families. MODY is caused by a mutation in a single gene. a parent has this gene mutation, any child they have, has a 50% chance inheriting it from them. If a child does inherit the mutation the/she will gradually develop MODY before they’re 25, whatever their weight, ethnic group etc. Neonatal diabetes:- Neonatal diabetes is a form of diabetes that is diagnosed under the age of nine months. It’s a different type of diabetes than the more common Type 1 diabetes as it’s not an autoimmune condition (where the body has destroyed it’s insulin producing cells)

16. ETIOLOGY the main etiologies are: Insulin Dependent Diabetes Mellitus – Genetic factor Environmental factor – Environmental factor have a role in the development of diabetes, because the highest incidence of new cases of Insulin Dependent Diabetes Mellitus occur during seasonal variations. Injection with certain viruses and organism attached the islet cells of the pancreas. There is some autoimmune response in the development of Insulin Dependent Diabetes Mellitus. Apparently some trigger causes the body to develop islet cell antibodies and anti insulin antibodies. Non Insulin Dependent Diabetes Mellitus:- Heredity Obesity – overweight clients require more insulin for metabolizing the food they eat. Hyperglycemia develops when the pancreas cannot secret enough insulin to match the body’s need when the number of insulin receptors site is decreased or altered. Increase age – Increase age may also be a risk because the pancreas becomes sluggish with age in client who is already predisposed to diabetes.

17. 3.Gestational Diabetes Causes When you eat, your pancreas releases insulin, a hormone that helps move a sugar called glucose from your blood to your cells, which use it for energy. During pregnancy, your placenta makes hormones that cause glucose to build up in your BLOOD Usually , your pancreas can send out enough insulin to handle it. But if your body can’t make enough insulin or stops using insulin like it should, your blood sugar levels rise , and you get gestational diabetes . . - The main risk factors are: Family history- family history of diabetes mellitus Obese Suffer from excessive thirst, hunger, urination and weight loss Has a family history of diabetes Over the age of 40 years. RISK FACTOR

18. CLINICAL FEATURES Risk factors of infection, trauma omission of medication Malaise Weight loss Polyuria, Polydipsia, Nausea, vomiting, abdominal distension Confusion, lethargy Hypotension, arrhythmias Severe dehydration Acetone breath Glycosuria and ketonuria Most patients are discovered while performing urine glucose screening

19. The main cardial sign of the diabetes mellitus; Polyuria : - because of hyperglycemia hyperosmolarity occur, resulting increased blood volume, increased renal blood flow, and the hyperglycemia act as an osmotic diuretic resulting increasing urine output . Polydipsia : - Polyuria cause dehydration, the mouth become dry and thirst sensor are activated causing the person to drink increase amount of fluid. Glucoseuria : - glucose is excreted in urine, a condition is called glucoseuria . Polyphagia : - because glucose cannot enter the cell without insulin, energy production decrease it stimulate hunger, and the person eat more food. Weight loss : - weight loss occurs in diabetes mellitus. The client with insulin dependent diabetes mellitus usually present with cardial sign and symptom already has complications. Clint with non insulin dependent diabetes mellitus may also develop the cardial sign and symptoms usually develop more slowly in non insulin dependent diabetes mellitus because many of these clients are elderly and may not recognized the abnormal thirst or frequent urination as abnormal for their age. More commonly, they may only experience visual blurring, neuropathic complication or infections.

20. OTHER SYMPTOMS INCLUDE Fatigue Weakness Sudden vision changes Tingling or numbness in hands or feet. Dry skin Skin lesions or wounds that are slow to heal & recurrent infections The onset of type 1 diabetes may also be associated with sudden weight loss or nausea, vomiting or abdominal pains, if DKA has developed.

21. P A THO P H Y S I OLGY Due to etiological factor ↓ The production of insulin is decrease ↓ It leads to imbalance between insulin supply and insulin demand ↓ Resulting in increase glucose production and decrease glucose utilization Intracellular hypoglycemia ↓ Glucogenesis and gluconeogenesis ↓ Breakdown of fats ↓ High levels of ketones ↓ Diabetic ketoacidosis extracellular hypoglycemia ↓ blood glucose > renal threshold ↓ glucoseuria urine has a high SG ↓ osmotic diuretic -Polyuria -Polydipsia -hypocalcaemia -hyponatraemia

22. History taking Physical examination Blood pressure Body mass index Skin examination Neurologic examination Food examination DIAGNOSTIC EVALUATION

23. Blood glucose (blood sugar):- A blood sample is taken for determination of glucose level. Fasting blood sugar - For FBS test, the client may not eat for 4 hrs, but water intake may continue. If the client is being infused with a dextrose intravenous solution. Average normal value for adult are 70 to 110mg/100ml but vary with age. As a general rule in an adult, a fasting blood sugar level over 140 mg for two to their consecution test may indicate diabetes. Random blood glucose - For random blood glucose, blood can be drawn at any time throughout the day, a random blood glucose level of 200mg/dl higher in persons who have symptoms of diabetes mellitus. Oral glucose tolerance test - OGTT is a most sensitive test for diagnosing diabetes. Urine and serum Keaton test . urine methods measure either acetoacetate or acetoacetate and acetone but do not usually detect beta- hydroxybutyrate . Blood ketones may be measured in a laboratory or with a handheld monitor . The laboratory test uses serum , the liquid portion of the blood, and typically measures acetoacetate .

24. HgbA1c Fasting lipid profile Test for microalbiminuria Serum creatinine level Urinalysis Electrocardiogram

25. MANAGEMENT MEDICAL MANAGEMENT:- The main goal of treatment in no normal insulin activity and blood the therapeutic goal within each type of diabetes is to achieve normal blood glucose without hypoglycemia and without seriously disrupting the patient’s usual activities. There are five component of management for diabetes; nutrition, exercise, monitoring, pharmacological therapy and education. Primary treatment of type 1 diabetes is insulin. Primary treatment of type 2 diabetes is control of weight loss. Exercise is important in enhancing the effectiveness of insulin. Use oral hypoglycemia agent if client and exercise are not successful in controlling blood glucose level. Insulin may be used in acute situations. Because treatment varies throughout course because of change in life style and physical and emotional status as well as advance in therapy, continuously assess and modify treatment plan as well as daily adjustment in therapy.

26. S. N. DRUG NAME ACTION DOSES ROUTE INDICATION CONTRA- INDICATION NSG. R ES P O N S I B I LITY 1. Acarbose An alpha glucosidase inhibitor that delay glucose absorption and digesion of c a r b o h y d r a t e . 25 mg 10mg 30mg PO Diabetic Mellitus Chronic intestinal disease, cirrhosis, colonic ulceration, hypersensitivit y To check blood glucose level, Advice the patient not to skip or delay meals. 2. Glipizide A second generation sulfonylurea that promote the release of insulin from beta cells of the pancreas and increase insulin sensitivity. PO D i a b e ti c M e ll it u s Diabetic ketoacidosis with or without coma, type 1 diabetes mellitus. Monitor the patient blood glucose level & food intake. Make sure the patient is aware of the typical sign & symptoms of hypo- glycemia &hyperglyce mia. 3. P i o g l it a - zone An antidiabetic that improves target cell response to insulin without increasing pancreatic insulin secretion. PO Diabetic mellitus, c o m b i n a ti o n therapy Active hepatic disease, diabetic ketoacidosis, increase serum transaminase level. Check p a ti e n t ’ s hepatic enzyme level. Instruct the patient to carry candy sugar packets, or chest pain. PHARMACOLOGIC MANAGEMENT

27. Oral hypoglycemic agent: - some client with NIDDM may require oral hypoglycemic agent for lowering blood glucose level. It is not insulin. Action : they lower the blood glucose in part by stimulating the pancreatic beta cell to release insulin. The average candidate for the oral hypoglycemic agents = is over the age of 40 years. = has no history of ketosis. = is not pregnant = is on less than 40 unit of insulin per day = has mild to moderate symptoms of hyperglycemia Contraindicated: - in clients with IDDM, pregnant or breastfeeding women, children, surgery client and those with allergy client to sulfa. Side effect:- hypoglycemia, especially in the elderly.

28. All clients with IDDM must inject insulin daily to survive. Some client with NIDDM may require insulin if diet, exercise and oral hypoglycemic agent are infective. Insulin lowers blood glucose by: Promoting the transport of glucose into the cell and, Inhibiting the conversion of glycogen and amino acid to glucose. There are several types of insulin Rapid acting Intermediate acting Long acting The absorption and duration of insulin varied by anatomic site. Insulin injected into the abdomen is absorbed fastest and as a consequence, the duration is shortest. Moving the injection site to the arm, leg or buttock, progressively slow absorption and lengthens duration . INSULIN THERAPY

29. Insulin sources:- there are three sources of insulin beef, pork and human. Insulin dosage :- insulin dosage varies greatly. Requirement :- the insulin requirement usually increase when a client Is seriously ill Develop an infection Undergoes surgery Suffer trauma Going through puberty Starting dose determined 0.5-1unit/kg body weight/day. Insulin pump : - small partable pump for the continuous administration of regular insulin are now some time used. Insulin pump often improved blood glucose control by mean of continuous subcutaneous insulin infusion. Complication of insulin pump :- Local infection at the injection site Hypoglycemia due to error in calculating insulin dosage or to punp malfunction Diabetic ketoacidosis due to injection of insufficient insulin to meet regular or increase metabolic need or to pump malfunction. SURGICAL MANAGEMENT Pancreas transplantation :- if the patient is unable to control blood sugar levels with conventional treatment a pancreas transplant may be considered, with a successful pancreas transplant, patient would no longer need insulin therapy .

30. NURSING MANAGEMENT

31. Obtain a history of current problem, family history, and general health history. Has the patient experienced Polyuria , Polydipsia , Polyphagia , and other symptoms? Number of years since diagnosis of diabetes. Family members diagnosed with diabetes, their subsequent treatment, and complications Perform a review of system and physical examination to assess for sign and symptoms of diabetes, general health of patients and presence of complications. General: recent weight loss or gain, increased fatigue, tiredness, anxiety Skin: skin lesion, infection, dehydration, evidence of poor wound healing Eyes: changes in vision floaters, halos, blurred vision, dry or burning eyes, cataracts, glaucoma. NURSING ASSESSMENT

32. NUTRITIONAL MANAGEMENT The dietary requirement for both type 1 and type 2 diabetes are critical but for different reasons for both types, for type 1 diabetes diet is necessary to be able to regulate dosage of insulin therapy. For type 2 diabetic diets is important to manage the blood weight control. Modifying eating habit are typically important steps toward reducing blood sugar level.

33. COMLICATION Long term complication of diabetes develop gradually, diabetes complication may be disabling or even life threatening. Possible complication includes; Cardiovascular disease :- diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain, heart attack, stroke and narrowing of arteries if have diabetes are more likely to have heart disease or stroke. Nerve damage (neuropathy):- excess sugar can injure the wall of the tiny blood vessels (capillary) that nourish nerve, especially in the legs. It can cause tingling, numbness, burring or pain that usually being tip of the toes. Damage to the nerve related to digestion can cause problem with nausea, vomiting, diarrhea or constipation. Kidney damage (nephropathy):- diabetic can damage the delicate filtering system it can lead kidney failure. Eye damage: - diabetic can damage the blood vessels of the retina (diabetic retinopathy), potentially lead to blindness. Foot damage: - nerve damage in the feet or poor blood flow to the feet increase the risk of various foot complication. Skin and mouth complication :- diabetes may leave patient more susceptible to skin problem including bacterial and fungal infection.