Lecture 5 – Diabetes: Types Treatments and Complications

Definition: A disorder in glucose metabolism, where the body’s ability to regulate glucose is impaired.
- Type 1 DM: Characterized by a lack of insulin production.
- Type 2 DM: Characterized by insulin resistance.

Not Related to Diabetes Mellitus: DI is a different condition with no glucose involvement.
- Cause: Polyuria (excessive urination) and polydipsia (excessive thirst) due to a deficiency in antidiuretic hormone (ADH), which leads to dehydration.
- Key Feature: High urine output, just like DM, but without glucose involvement—DI is primarily a fluid imbalance issue.
SIADH (Syndrome of Inappropriate ADH) vs. DI:
- SIADH: The opposite of DI, with low urine output (oliguria), no thirst, and fluid retention leading to overload.
  - SIADH causes decreased serum specific gravity (due to water retention) and increased urine specific gravity (due to low urine output).

Fluid Overload: Seen in SIADH (low urine output, fluid retention).
Fluid Volume Deficit: Seen in DM and DI (high urine output, dehydration).
Fluid Volume Excess: Also present in SIADH (water retention leading to overload).

Characteristics:
- Insulin-dependent
- Typically juvenile onset
- Ketosis-prone
Treatment: Remember “DIE” – Diet, Insulin, Exercise.
1. Insulin is the most important.
2. Exercise helps manage blood sugar.
3. Diet is the third priority.

Characteristics:
- Non-insulin dependent
- Adult onset
- Non-ketosis prone
Treatment: Remember “DOA” – Diet, Oral Hypoglycemics, Activity.
1. Diet (most important): Focus on restricting calories.
  - Patients typically follow a calorie-restricted diet (1200, 1400, or 1600 kcal) and should eat 6 small meals per day to maintain stable blood sugar levels and avoid spikes.
  - Question: What is the most important dietary action for DM2? Restrict calories first.
2. Activity: Physical activity improves insulin sensitivity.
3. Oral Hypoglycemic Medications: Third in priority for managing DM2.

Function: Insulin lowers blood sugar levels and is primarily used to manage Type 1 Diabetes Mellitus (T1DM).

Regular (R) – Clear, can be given via IV drip, short/intermediate-acting.
- Onset: 1 hour
- Peak: 2 hours
- Duration: 4 hours
- Pattern: 1-2-4
NPH (N) – Cloudy, suspension (requires mixing), not suitable for IV, intermediate-acting.
- Onset: 6 hours
- Peak: 8-10 hours
- Duration: 12 hours
- Pattern: 6-8-10-12
Lispro – Rapid-acting insulin, should be given with meals, not before.
- Onset: 15 minutes
- Peak: 30 minutes
- Duration: 3 hours
- Pattern: 15-30-3
Glargine – Long-acting insulin, minimal risk of hypoglycemia, safe to give at bedtime.
- Peak: None
- Duration: 12-24 hours

Example Question: If a patient is given 30 units of insulin at 7 am, when should you check for hypoglycemia?
- Answer: Add the insulin peak time to the time of administration.
- For NPH, peak is 8-10 hours. If given at 7 am, check for hypoglycemia around 3 pm to 5 pm.

Expiration:
- Always check the expiration date.
- Opening the insulin vial changes the expiration date to 30 days from the day it was opened.
- If the opened package is not labeled with a new expiration date, discard it.
- Refrigeration: Unopened insulin should be refrigerated. Once opened, refrigeration is optional, but it’s a good practice to keep it refrigerated at home.
Exercise:
- Exercise enhances the effect of insulin (like an extra dose), so reduce insulin dosage if the patient is scheduled to exercise.
- Provide fast-acting carbohydrates (juice, snack) after exercise.
Sick Days (e.g., flu, fever):
- Illness increases blood sugar levels, so insulin must still be administered even if the patient isn’t eating.
- Encourage fluids to prevent dehydration.
- Sick diabetic patients face two major problems: hyperglycemia and dehydration.

Causes: Too much insulin, too much exercise, or not enough food.
Signs and Symptoms:
- “Drunk-like” behavior: Staggering gait, slurred speech, impaired thinking, mood swings.
- Shock symptoms: Rapid heart rate, rapid breathing, low blood pressure, cold/clammy skin.
Treatment:
- Give sugar or rapidly metabolized carbs: juice, candy, regular soda, milk, honey, jelly.
- Best option: Sugar + starch or protein (e.g., apple juice and turkey).
- Bad option: Two sugars together (e.g., candy and soda).
- For unconscious patients: Do not give anything by mouth. Use glucagon IM (at home) or IV Dextrose (D10/D50) (in the ER).

Causes: Acute viral infection (often within 2 weeks), too much food, not enough insulin, or lack of exercise.
Signs and Symptoms (DKA):
- Dehydration: Dry skin, poor skin elasticity, warm skin.
- Ketones in blood, Kussmaul’s breathing, and high potassium (K+).
- Acidosis: Acetone breath, anorexia, nausea.
Treatment:
- IV insulin (Regular).
- IV fluids (rapid rate, e.g., 200 ml/hr).

Key Difference: No ketones or acidosis.
Main Issue: Severe dehydration.
Signs and Symptoms: Dry, flushed skin, poor skin turgor, increased heart rate.
Nursing Diagnosis: Fluid Volume Deficit (Dehydration).
Treatment: Rehydration.
- Positive Outcomes: Increased urine output, moist mucous membranes.

Insulin Dependence: DKA patients (Type 1 DM) are more dependent on insulin, while HHNK patients (Type 2 DM) need rehydration.
Mortality Rate: More patients die from HHNK.
Priority: DKA is a higher priority since it responds quickly to insulin, while HHNK does not respond as fast to treatment.

Causes: Poor tissue perfusion or peripheral neuropathy.
Examples:
- Renal failure (from poor perfusion).
- Gangrene, heart failure, urinary incontinence (from neuropathy).
- Patients may not feel injuries (e.g., a burn on the foot) due to neuropathy.
Lab Test for Long-Term Blood Sugar Control:
- HbA1c (Glycosylated Hemoglobin): Reflects average blood sugar over the last 90 days.
- Normal: HbA1c < 6.
- Out of Control: HbA1c > 8.
- Borderline: HbA1c = 7 (requires further evaluation).