DM PPT including recent advances

1. DIABETES MELLITUS
SUDESHNA BANERJEE
M.SC (N) 2ND YEAR

2. PANCREAS

3. Soft, lobulated elongated
gland with both exocrine
and endocrine functions
Exocrine –pancreatic juice
Endocrine-insulin
Located in epigastric &
left hypochondriac regions

4. HORMONES
Insulin by beta cells
Glucagon by alpha cells
Somatostatin by delta cells
Pancreatic polypeptide by F cells

5. CONT…
Pancreas secretes 40-50 units of insulin daily in
two steps:
Secreted at low levels during fasting
Increased levels after eating (prandial)
An early burst of insulin occurs within 10
minutes of eating
Then proceeds with increasing release as long
as hyperglycemia is present

6. INSULIN
Synthesized in the beta cells of the islets of Langerhans
50-60% damage of the islet cell mass needed for diabetes to
become apparent
Major stimulants
Glucose, amino acids, glucagon, CCK
Major inhibitors
Somatostatin, amylin

7. CONT…
• Insulin allows glucose to move into cells to
make energy
• Inhibits glucagon activity

8. NORMAL VALUES

9. GLUCAGON
Secreted by the alpha cells of the islets of
Langerhans
Major stimulants
Amino acids
Major inhibitors
Glucose, insulin, somatostatin

10. SOMATOSTATIN
Secreted by the delta cells of the islets of Langerhans
Inhibits gastric, pancreatic, and biliary secretion,
INSULIN & GLUCAGON
Major Stimulants
High fat, protein rich , high carbohydrate meal

11. DIABETES MELLITUS
Is a chronic disorder of carbohydrate,
protein, and fat metabolism resulting from
insulin deficiency or abnormality in the
use of insulin

12. TYPE 1 DIABETES
Insulin – Dependent Diabetes Mellitus
Destruction of beta cells of the pancreas little or
no insulin production
Autoimmune (Islet cell antibodies)/ Congenital
absence
May occur at any age, usually appears below age
15
Requires daily insulin admin

13. PATHOPHYSIOLOGY

14. TYPE II DIABETES
Non Insulin–Dependent Diabetes Mellitus
Disturbance in insulin reception in the
cells
Decrease number of insulin receptors
Loss of beta cell responsiveness to
glucose leading to slow or decreased
insulin release by the pancreas

15. CONT…
Occurs over age 40 but can occur in
children
Common in overweight or obese

17. TYPE 3 DIABETES
Insulin resistance in the brain associated with
Alzheimer’s Disease
Impaired glucose metabolism in the brain plays a
role in the development of Alzheimer’s by
depriving cells of energy

18. TYPE 4 DIABETES
Not associated with insulin deficiency or obesity
Has been discovered in lean mice
Abnormally high levels of immune cells called T regulatory
cells (Tregs) inside their fat tissue
Age-related insulin resistance that occurs in lean, elderly
people

19. PRE-DIABETES
Impaired glucose tolerance (IGT)
FPG- 100-125mg/dL
OGTT 140-199mg/dL
HbA1c 5.7-6.4%

20. RISK FACTORS

22. DIAGNOSTIC TESTS

23. CONT…

24. GLYCATED HEMOGLOBIN (HBA1C):--
This blood test indicates the average
blood sugar level for the past two to three months
It measures the percentage of blood sugar
attached to hemoglobin(Glycated Hb)
Glycated Hb is a substance in red blood cells that is
formed when blood sugar (glucose) attaches to
hemoglobin

25. CONT…
An A1C level of 6.5 percent or higher on two
separate tests indicates that patient have
diabetes
An A1C between 5.7 and 6.4 percent indicates
pre diabetes
Below 5.7 is considered normal

26. KETONURIA:--
Urine levels of ketones can be tested by clients’
use of dip-strips
The presence of ketone in the urine indicates that
the body is using fat as a major source of energy,
which may result in ketoacidosis
Although urine testing for checking ketones, urine
testing for glucose is not a reliable method for
monitoring

27. DIAGNOSTIC CRITERIA
Classic signs of HYPERGLYCEMIA with RBS
≥200mg/Dl
OGTT ≥200mg/dL
FPG ≥126mg/dL
A1C ≥ 6.5%

28. TREATMENT MODALITIES
ORAL HYPERGLYCEMIC AGENTS
These include improve the effectiveness of the body's natural
insulin, reduce blood sugar production, increase insulin
production and inhibit blood sugar absorption. Oral diabetes
medications are sometimes taken in combination
with insulin.

30. INSULIN THERAPY
Insulin divided into:-
Prandial insulin is administered pre-meal because of its short
or rapid onset of action for controlling the post-prandial
glucose excursion. It is also used in insulin pumps.
Basal insulin is administered once or twice daily. The
intermediate or long-acting pharmacokinetic profile covers
the basal insulin requirements in between meals and
overnight due to endogenous hepatic glucose production.

31. CONT…
Premixed insulin is biphasic insulin that incorporates
the combination of short or rapid-acting insulin with
its intermediate-acting counterpart into a single
preparation to cover for both postprandial glucose
excursion as well as basal insulin needs
simultaneously

32. TYPES OF INSULIN

33. INHALATIONAL INSULIN
Inhalable insulin is a powdered form of insulin, delivered
with a nebulizer into the lungs where it is absorbed
Adverse reactions:
Insulin acting as a local Growth Factor
Local alveolar membrane morphological changes

34. CONT…
Contraindications:
• Smokers and ex-smokers (6 months)
• Patients with poorly controlled lung disease
• Allergic patients

35. EXUBERA AFREZZA

36. CONTINUOUS SUBCUTANEOUS INSULIN
INFUSION(CSII)
 Portable infusion devices with S.C cannula
 Only rapid or regular insulins are used
 Programmed to deliver at low basal rates
( 1U/hr) & premeal bolus (4-10 times of basal rate)

37. INSULIN INJECTION SITES

38. TEACH PT. ON CORRECT ADMINISTRATION OF
INSULIN AND OTHER HYPOGLYCEMIC AGENTS
Insulin in current use may be stored at room temp.,
all others in ref. or cool area
Avoid injecting cold insulin lead to tissue reaction
Roll insulin vial to mix, do not shake, remove air
bubbles from syringe

40. ACUTE COMPLICATIONS OF DM
Diabetic ketoacidosis
Diabetic ketoacidosis (DKA) is an acute and dangerous
complication that is always a medical emergency and requires
prompt medical attention
Low insulin levels cause the liver to turn fatty acid to ketone
for fuel (i.e., ketosis); ketone bodies are intermediate
substrates in that metabolic sequence
Elevated levels of ketone bodies in the blood decrease the
blood's pH, leading to DKA

41. CONT…
Sign & symptoms of DKA:-
Ketonuria
Metabolic acidosis
Kussmaul’s respiration
Acetone breath
Flushed face
Tachycardia

42. HYPOGLYCEMIA
 Low blood glucose (usually below 60mg/dl)
 Results from too much insulin, not enough food,
and/or excessive physical activity
 May occur 1-3 hrs after regular insulin injection
S/Sx:
Sweating, tremor, pallor, tachycardia, palpitations and
nervousness
caused by release of epinephrine from the CNS when
blood glucose falls rapidly

43. Management of hypoglycemia
Give simple sugar orally if pt. is conscious and can
swallow – orange juice, candy, glucose tablets, lump
of sugar
Give Glucagon if pt. is unconscious or cannot take
sugar by mouth
If pt. does not respond to the above measures, he is
given 50 ml of 50% glucose I.V. or 1000 ml of 5%-10%
glucose in water I.V.

44. Diabetic coma
Diabetic coma is a medical emergency in which a person with
diabetes mellitus is comatose (unconscious) because of one
of the acute complications of diabetes:
Severe diabetic hypoglycemia
Hyperosmolar nonketotic coma in which extreme
hyperglycemia and dehydration alone are sufficient to cause
unconsciousness.

45. Insulin shock
Low blood sugar
Causes:
• Overdose of exogenous insulin
• Eating less

46. SIGN & SYMPTOMS OF INSULIN SHOCK:-
 Irritability
 Sweating
 Trembling
 Tachycardia
 Pallor
CLINICAL FINDING :
BLOOD GLUCOSE BELOW 55-60 mg/dl

47. Preventing Hypoglycemic Reactions Due
to Insulin
Instruct the pt. as follows:
Hypoglycemia may be prevented by
maintaining regular exercise, diet and insulin
Early symptoms of hypoglycemia should by
recognized and treated

48. Cont…
Carry at all times some form of simple
carbohydrate (orange juice, sugar, candy)
Extra food should be taken before unusual physical
activity or prolonged periods of exercise
Between-meal and bedtime snacks may be
necessary to maintain a normal glucose level.

49. CHRONIC COMPLICATIONS OF
DIABETES MILLETUS
• Degenerative changes in the vascular system
–Undernourishment
–Atherosclerosis
Heart disease
MI from
atherosclerosis

50. Eye complications
• Cataract
• Diabetic retinopathy
• Retinal detachment

51. Cont…
Neuropathy from:
• Vascular insufficiency
• Hyperglycemia

52. Nephropathy
• Damage & obliteration of capillaries supplying the
kidney
Liver changes
• Enlargement &
• fatty infiltration

53. Skin changes:
Diabetic dermopathy – hyperpigmented & scaly
pretibial areas (acanthosis nigricans)

54. Complications cont…
• Diabetic myonecrosis ('muscle wasting')
• Peripheral vascular disease, which contributes to
intermittent claudication
• Immunocompromise: Hyperglycemias impairs the
ability of leukocytes to destroy bacteria. Lowered
resistance to certain infections

55. FOOT CARE TIPS
Inspect your feet every day:
Look at your bare feet everyday for cuts, blisters,
red spots and swelling
Use a mirror to check the bottoms of you feet, or
ask a family member for help if you have a trouble
seeing
Check for change in temperature

56. CONT…
Wash your feet every day:
Wash your feet in warm, not hot water
Dry your feet well. Be sure to dry between the toes
Do not soak your feet
Do not check water temperature with your feet
Keep the skin soft and smooth:
Rub a thin coat of skin lotion over the tops and bottoms of
your feet, but not between your toes

57. CONT…
Trim your toenails each week or when needed:
 Trim your toenails straight across, and file the edges with
an emery board or nail file
 Wear shoes and socks at all times
 Never walk barefoot
 Wear comfortable shoes that fit well and protect your feet

58. NURSING DIAGNOSIS
Risk for Injury Related to Sensory
Alterations
Interventions and foot care practices:
Cleanse and inspect the feet daily
Wear properly fitting shoes
Avoid walking barefoot
Trim toenails properly
Report non-healing breaks in the skin

59. CONT…
Risk for Impaired Skin Integrity
Wound Care:
Debridement
Elimination of pressure on infected
Growth factors applied to wounds

60. Risk for Injury Related to Disturbed
Sensory Perception: Visual
Interventions include:
Blood glucose control
Environmental management
Incandescent lamp
Coding objects
Use of adaptive devices

61. LIFESTYLE
EAT
HEALTHY
DO
EXERCISE
GO FOR
REGULAR
CHECKUPS
MANAGE
STRESS
STOP
SMOKING
&
DRINKING
ALCOHOL