Chapter 33: Diabetes Mellitus and the Metabolic Syndrome

Signs and Symptoms of Diabetes (3):

**Three Polys 1. Polyuria. 2. Polydipsia. 3. Polyphagia.

Type 2 Diabetes Mellitus is more common in obese adolescents and children (2):

1. 90-95% of diabetes. 2. 40 years old, and often overweight.

Criteria for Diagnosis of Metabolic Syndrome (5):

1. Abdominal Obesity: Waist circumference >35 inches in women, and >40 inches in men. 2. Triglycerides >150 mg/dL. 3. HDL <50 mg/dL in women or <40 mg/dL in men. 4. Blood Pressure >130/85 5. Fasting Blood Sugar >100 mg/dL.

Signs and Symptoms of Hypoglycemia (4):

1. Anxiety. 2. Tachycardia. 3. Sweating. 4. Cool and clammy skin.

Type 1 Diabetes Mellitus (4):

1. Autoimmune. 2. Causing the pancreas not to be able to produce insulin. 3. Commonly occurs in young people. 4. 5-10% of diabetes.

Disorders of Gastrointestinal Motility (5):

1. Constipation. 2. Diarrhea. 3. Nausea and vomiting. 4. Dyspepsia (abdominal discomfort). 5. Gastroparesis (delay of emptying stomach).

Macrovascular Complications from Diabetes [Major Risk For] (3):

1. Coronary artery disease. 2. Cerebrovascular disease. 3. Peripheral vascular disease.

Diabetic Neuropathy [Autonomic Neuropathy] (4):

1. Defects in vasomotor and cardiac responses. 2. Impaired motility of the GI tract. 3. Inability to empty the bladder. 4. Sexual dysfunction.

Acute Complications of Diabetes (5):

1. Diabetic Ketoacidosis (DKA). 2. Hyperglycemic Hyperosmolar Nonketotic Coma. 3. Hypoglycemia. 4. Somogyi Effect. 5. Dawn Phenomenon.

Diabetic Neuropathy [Somatic Neuropathy] (2):

1. Diminished perception of vibration, pain, and temperature. 2. Hypersensitivity to light touch; occasionally severe "burning" pain.

Protein Metabolism (4):

1. Essential for the formation of all body structures, including genes, enzymes, muscles and hemoglobin of RBCs. 2. Remember, the body holds onto this. 3. Amino acids are foundation of proteins. 4. Excess amino acids, are converted to fatty acids, ketones, and glucose.

Hypoglycemia (4):

1. Excess insulin in the blood. 2. Below normal blood glucose levels. 3. Chronic alcoholics are prone to hypoglycemia. 4. Glucose is important to the brain for functioning, lack of glucose causes: *Headache. * Seizures. *Altered behavior. *Coma. *Difficulty with problem solving.

Risk Factors for Diabetic Nephropathies (6):

1. Genetics. 2. Hypertension. 3. Hyperlipidemia. 4. Poor glycemic control. 5. Smoking. 6. Microalbuminuria.

Glucose Regulating Hormones (2):

1. Glucagon. 2. Insulin.

Glucose Metabolism (4):

1. Glucose is efficient fuel for the brain, nervous system and other organs and tissues. 2. Glucose is ingested into: The GI tract--> Portal Vein--> Liver--> Circulation. 3. Tissues receive glucose from the blood. 4. Moderate to severe hypoglycemia leads to brain dysfunction or death.

Glucose Metabolism (3):

1. Glycogenesis. 2. Glycogenolysis. 3. Gluconeogenesis.

Neurologic Signs of Hyperosmolar Hyperglycemic Nonketotic State (7):

1. Hemiparesis. 2. Babinski reflexes. 3. Aphasia. 4. Muscle fasciculations. 5. Hyperthermia. 6. Seizures. 7. Coma.

Three Major Classifications of DKA:

1. Hyperglycemia: **Blood glucose levels >250mg/dL. 2. Ketosis: **(BHB) serum blood test. 3. Metabolic Acidosis: **Sodium Bicarbonate <22 mEq/L **Low pH <7.35

Chronic Complications of Diabetes Mellitus (4):

1. Increased glucose levels allow glucose to bind to proteins in: 2. Hemoglobin-->Hb A1c has higher O2 affinity. 3. Basement membranes of blood vessels. **Nephropathy. **Retinopathy. **May cause increased risk of atherosclerosis. 4. Lens-->Cataracts.

Oral Antidiabetic Agents (5):

1. Insulin Secretagogues: *Sulfonylureas. *Glipizide (Glucotrol) *Glyburide (Diabeta) *Glimpiride (Amaryl) 2. Biguanides: *Metformin 3. a-Glucosidase *Acarbose (Precose) 4. DDP-4 Enzyme Inhibitors: *Sitagliptin 5. Thiazolidinediones *Pioglitazone (Acots)

Metabolic Syndrome (2):

1. Major factor for people with metabolic syndrome is OBESITY. 2. Obese people have an increased resistance to insulin and inability for the liver to control the glucose levels. *Hyperglycemia. *Hyperinsulinemia.

Diabetes Management Treatment Plans (4):

1. Medical nutrition therapy. 2. No specific ADA diet anymore. 3. Diet should be based on nutritional assessment and treatment goals. 4. Insulin Injections. (SubQ)

Diabetic Foot Ulcers (2):

1. Most common complication leading to hospitalization among diabetes. 2. Common Sites: *Back of heel. *The plantar metatarsal area. *The great toe.

DKA (3):

1. Most commonly occurs in patients with Type 1 Diabetes. 2. Break down of fatty acids into glycerol with the increase of fatty acids leads to ketone build-up by the liver. 3. This is an emergency situation.

Fat Metabolism (4):

1. Most efficient form of fuel storage. 2. Many carbohydrates consumed in the diet are converted to triglycerides for storage in adipose tissue. 3. Fatty acid degradation occurs in large part in the liver than converts some fatty acids into ketones and release into blood. 4. Ketones break down to form acetone, acetoacetic acid, and beta hydroxybutate all acids.

Hyperosmolar Hyperglycemic Nonketotic State (6):

1. Most frequently seen in Type 2 Diabetes. 2. Hyperglycemia: **Blood Glucose > 600 mg/dL. 3. Hyperosmolarity. **Plasma > 320 mOsm/L. 4. Dehydration. 5. The absence of ketones--This is key. 6. Depression of sensorium.

Signs and Symptoms of DKA (11):

1. Nausea. 2. Vomiting. 3. Fruity smell. 4. Abdomen pain and tenderness. 5. Polyuria. 6. Marked fatigue. 7. Hypotension. 8. Tachycardia. 9. Kussmaul respirations. 10. Metabolic acidosis. 11. Eventual stupor.

Common Causes of Metabolic Syndrome (5):

1. Obesity. 2. High levels of LDL. 3. Low levels of HDL. 4. Hypertension. 5. CAD, CVA, PAD.

Macrovascular Complications from Diabetes Risk Factors (6):

1. Obesity. 2. Hypertension. 3. Hyperglycemia. 4. Hyperinsulinemia. 5. Altered platelet function. 6. Elevated fibrinogen levels.

Risk Factors for Retinopathies (3):

1. Poor glycemic control. 2. Elevated blood pressure. 3. Hyperglycemia.

Type 2 Diabetes Mellitus is described as (3):

1. Presence of hyperglycemia with insulin deficiency. 2. Peripheral insulin resistance. 3. Increased glucose production by the liver.

Hemoglobin (A1C) Testing (2):

1. Provides blood glucose levels from the previous 6 to 12 weeks. 2. A1C levels should be less than 7% according to the ADA.

Other Signs and Symptoms of Diabetes (4):

1. Recurrent blurred vision. 2. Fatigue. 3. Paresthesia. 4. Skin infections.

Diabetes Mellitus (2):

1. Significant risk factor in coronary artery disease, cerebrovascular accident (CVA), blindness, end stage renal disease, lower leg amputation. 2. Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age.

Goals of DKA (4):

1. To improve circulatory volume and tissue perfusion. 2. Decrease blood glucose. 3. Correct the acidosis. 4. Correct electrolyte imbalance.

Criteria for Diagnosis of Type 1 Diabetes Mellitus (4):

1. Type 1 Diabetes is characterized by three items. 2. There is an absolute lack of insulin. 3. Elevated glucose. 4. Breakdown of body fats and proteins causing ketones in the urine and serum ketones or acetone in the blood.

Hyperosmolar Hyperglycemic Nonketotic State Signs and Symptoms (4):

1. Weakness. 2. Dehydration. 3. Polyuria. 4. Excessive thirst.

Potassium often decreases due to administering regular intravenously. Insulin drive the potassium back into the cells.

Correct electrolyte imbalance.

Sodium bicarbonate intravenously.

Correct the acidosis.

The patient becomes hyperglycemic around 0500 and 0900.

Dawn Phenomenon

Regular insulin intravenously.

Decrease blood glucose.

Treatment for Unresponsive Hypoglycemia Patients with IV access:

Dextrose intravenously 25% to 50%.

Leading cause of kidney disease.

Diabetic Nephropathies:

Type 2 diabetes--decrease in body fat, better weight control and improve insulin sensitivity.

Exercise

Diabetes Blood Tests (6):

Fasting Blood Sugar 1. 100-126 mg/dL (Pre-diabetes). 2. >126 mg/dL (Diabetes). 3. Preferred diagnostic test. 4. No food for at least 8 hours. 5. Causal Plasma Glucose: >200 mg/dL 6. Capillary blood glucose monitoring.

S&S of Diabetes. Due to lower plasma volume.

Fatigue

Treatment for Unresponsive Hypoglycemia Patients with no IV access:

Give Glucagon IM.

Maintains blood glucose between meals and during periods of fasting.

Glucagon

The liver synthesizes glucose from amino acids, glycerol and lactic acid.

Gluconeogenesis.

Liver removes glucose from the circulation and converts it to glycogen to store or converted into fat.

Glycogenesis.

Degradation of stored glycogen--liver glycogen stores are broken down and released into the circulation.

Glycogenolysis.

Insulin Resistance and Metabolic Syndrome with Type 2 Diabetes:

Insulin resistance previously called Syndrome X, but now called "Metabolic Syndrome"

Allows cells to take up glucose from the blood.

Insulin.

Signs and Symptoms of Diabetic Nephropathy:

Microalbuminuria now as urine protein between 30 and 300 mg.

Treatment for Responsive Hypoglycemia Patients:

Oral glucose, or orange juice.

S&S of Diabetes. Reflects a temporary dysfunction of the peripheral sensory nerves.

Paresthesia

(Excessive thirst) Water is pulled out of the cells due to the rise of glucose levels causing intracellular dehydration.

Polydipsia

(Excessive hunger) Usually is not present in people with Type 2 diabetes.

Polyphagia

(Excessive urine) The kidneys are trying to flush out the high glucose levels.

Polyuria

Diabetic Nephropathies:

Prevention is Key: *Achieve glycemic control. *Maintenance of blood pressure. *Prevention or reduction in the level of proteinuria. *Treatment of hyperlipidemia. *Smoking cessation.

S&S of Diabetes. Due to the lens and retina are exposed to hyperosmolar fluid.

Recurrent Blurred Vision

What is the only Insulin that is given IV?

Regular insulin is the only insulin that is given IV.

Most common pattern of eye disease:

Retinopathy

S&S of Diabetes. Hyperglycemia loves the yeast organisms.

Skin Infections

The patient becomes hypoglycemic at 0300 then the body responds by secreting glucose therefore causing a hyperglycemic episode.

Somogyi Effect

Intravenous solution 0.9% normal saline.

To improve circulatory volume and tissue perfusion.

Osmolarity in Diabetes Mellitus

When blood glucose is high it causes dehydration because: *There is an increased blood osmolarity which causes the cells to shrink. *Therefore it pulls all of the fluid out of the cells including the brain.