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A Guide to Diabetes MellitusDanielle ConnorFrostburg State UniversityA Guide to Diabetes MellitusDiabetes Mellitus (DM) is a chronic disease that affects people of all ages, races, social economic statuses, and genders. “Today there are around 250 million people worldwide who are living with this condition and this figure is predicted to rise to 366 million in the next twenty years” (Meetoo & Allen, 2010). The healthcare system has an obligation to facilitate prevention, early detection, treatment, and management of this disease. The World Health Organization (2013) predicts that diabetes may grow to be the seventh leading cause of death by 2030. Many different organ systems are negatively affected by this breakdown in carbohydrate metabolism and insulin production. In order to provide safe, appropriate, and cost effective care, health care providers must understand the pathophysiology of the disease, the harmful effects to other organ systems, and have the ability to access and critique the educational tools available to patients. The goal of this group project and paper is to provide insight into these areas of the disease.Disease and Pathophysiology Overview DM is a disease characterized by elevated blood glucose levels. Glucose is the body’s main source of energy. Normally when food is ingested, carbohydrates are broken down into glucose molecules in the digestive tract. These glucose molecules are absorbed into the bloodstream, which increases glucose levels in the blood. As blood glucose levels rise, the beta cells of the pancreas are stimulated to release insulin. The hormone insulin binds to cell receptors that enable glucose to enter the cells, taking it out of the bloodstream. Once it has entered the cell, glucose is used for energy. The lower level of glucose circulating through the bloodstream will result in decreased secretion of insulin by the pancreas. Excess glucose can be stored in the liver or muscles in the form of glycogen. When energy is needed, glycogen is converted to glucose through the process of glycogenesis to provide a quick energy source. When insulin production or secretion is altered, as with diabetes mellitus, this process does not work properly. If insulin production is decreased, glucose cannot effectively enter the cells and remains circulating in the bloodstream resulting in hyperglycemia. DM is classified into three types: type I Insulin Dependent Diabetes Mellitus (type I), type II Non-Insulin Dependent Diabetes Mellitus (type II), and gestational diabetes. While the pathophysiology may vary, all three types share some similar signs, symptoms, and complications. The outcome of each disorder is hyperglycemia and the resulting complicationsIn type I DM, there is a marked deficiency of insulin production by the beta cells of the pancreas. When insulin is not released into the bloodstream, glucose is unable to enter cells as an energy source, cannot be stored, and will remain in the bloodstream resulting in postprandial hyperglycemia. When hyperglycemia persists and the glucose concentration in the blood is elevated, the kidneys are unable to reabsorb filtered glucose and it spills over into the urine (glycosuria). Glycosuria is usually accompanied by fluid and electrolyte loss, which leads to increased thirst (polydipsia) and increased urine output (polyuria). Type I diabetics tend to have weight loss due to the high amount of glucose that is being excreted in the urine. Type I DM most often develops in childhood or during the teenage years. While uncommon, adults can develop type I DM. This type of DM is thought to be an autoimmune disease and is suspected “to follow exposure to an environmental trigger such as an unidentified virus, stimulating an immune attack against the beta cells of the pancreas in some genetically predisposed people” (Judd, 2011, p. 5). These attacks can greatly reduce or completely shut down the insulin excretion from the pancreas, therefore, a type I diabetic is dependent on exogenous insulin for survival.A serious complication of type I diabetes is diabetic ketoacidosis (DKA), a disorder in which fat is broken down to meet the body’s energy needs. Fatty acids are converted to ketone bodies, acids that will disturb the acid-base balance of the body. High levels of ketones can cause extreme sickness, coma, or death. Type II diabetes, the most common form of diabetes, is also called “adult onset diabetes.” Type II is not an autoimmune disease. There are two problems related to insulin in type II diabetes: insulin resistance and impaired insulin secretion. Insulin resistance is a lack of sensitivity of the tissues to insulin. Normally, insulin is able to bind to receptors on cells. Insulin resistance is associated with a decrease in cellular reactions and the insulin is less effective at stimulating glucose uptake by tissues and cells. To compensate for insulin resistance and prevent hyperglycemia, the body should increase the amount of secreted insulin. However, individuals with type II diabetes have impaired insulin secretion by the beta cells of the pancreas, and glucose levels continue to rise. When hyperglycemic symptoms are experienced, they include: fatigue, polyuria, polydipsia, irritability, and blurred vision. Poor wound healing and infections (bladder and vaginal in women) can also occur because hyperglycemia impairs the body’s healing process and ability to ward off infection. It has been found that “people who are overweight are more likely to have insulin resistance because fat interferes with the body’s ability to use insulin” (Judd, 2011, p. 45). Type II diabetes may also require insulin for survival if glucose levels cannot be controlled by diet, exercise, and oral hypoglycemics. Gestational diabetes occurs in pregnancy. This type of diabetes can develop due to increases in estrogens, progestins, and other pregnancy related hormones. As pregnancy progresses, postprandial glucose levels increase as insulin sensitivity decreases. To maintain normal glucose levels during pregnancy, maternal insulin secretion must increase to counteract the decreased insulin sensitivity. When this increased insulin secretion cannot meet the new demand, gestational diabetes occurs. This usually occurs in the second half of pregnancy and resolves spontaneously after childbirth. It is believed that having gestational diabetes can predispose a woman to developing Type II diabetes later in life. DM’s Effect on Selected Organ SystemsOrgan System One: The Renal SystemDM is the leading cause of end-stage renal disease. Approximately two thirds of cases of end-stage renal disease are said to result from complications of DM. Patients in the last stage of renal disease have a high mortality rate of about 19-24%, and about 90,000 die each year (Lewis, 2011, p. 1171). Although patients are aware that they have diabetes, it is likely that they are not aware that they may have nephropathy. Patients with chronic kidney disease are usually asymptomatic, which leads to the disease being under diagnosed and undertreated. About 70% of people with chronic kidney disease are unaware that they have it (Lewis, 2011, p. 1171).Kidneys help maintain the composition and volume of body fluids, filter blood, excrete waste products, and retain what is needed. The nephron is the basic structural and functional unit of the kidneys. Each kidney has about 1 million nephrons (Taylor, 2011, p. 1223). Nephrons are like filters that either reabsorb or excrete substances from our blood stream. The nephrons excrete products of metabolism that our bodies do not need in our blood stream, such as urea, creatinine, and uric acid. The nephrons selectively reabsorb and excrete water, electrolytes, and other substances from our blood. Urine is then formed from substances that the nephrons choose to excrete.In patients with diabetes, high blood sugar levels cause a larger amount of blood to be filtered through the kidneys, putting an extra workload on the kidneys. Over the years, the nephrons can become thickened and scarred. The nephrons start to leak, causing substances that were meant to be reabsorbed to leak into the urine. Protein (albumin) and red blood cells are the main substances that need to be reabsorbed into our bodies by the nephrons, but in someone with renal disease, these important substances get excreted. Diabetes does not always lead to nephropathy. According to the American Diabetes Association (2013), keeping blood sugar levels in a target range can help to reduce the risk of micro albuminuria by one third. Medline Plus (2013) suggests that patients with diabetes should aim for a target range of 70-130 mg/dL before meals. After eating meals their blood sugar levels will rise, but it is best to aim for levels less than 180 mg/dL two hours after a meal. Also, diabetics will often be put on an ACE inhibitor to help protect the kidneys even if they do not have high blood pressure. It is recommended that diabetics eat the same amount of protein as the rest of the population. Fifteen to twenty percent of total calories consumed should be from protein, but diabetics are advised to avoid eating a high protein diet in order to protect the kidneys (Lewis, 2011, p.1232)Organ System Two: The Cardiovascular SystemDiabetes Mellitus can lead to many medical problems involving the cardiovascular system. Cardiovascular disease is a serious and possibly life threatening complication of diabetes. “Diabetes mellitus appears to lead to cardiovascular disease through the process of atherosclerosis, which is a narrowing of the arteries caused by the build-up of plaque deposits beginning with damage to the inner layer of the artery walls (endothelium)” (American Medical Association [AMA], 2008, p. 106). When arterial walls are damaged, lipid-causing plaque builds up on the walls. The ability of arterial walls to expand has also been impaired by hyperglycemia, rendering the body more prone to develop clots. Atherosclerosis is the process that causes peripheral artery disease (PAD) and coronary artery disease (CAD). “PAD affects eight to twelve million people in the U.S.” (Sutton, 2010, p. 263). This occurs when blood vessels in the legs become occluded by plaque build-up. Pain in the leg muscles is a common symptom, especially during periods of exertion. This symptom is referred to as intermittent claudication, which means that muscles in the feet and legs are not receiving enough oxygen and blood while they are moving. Rest usually relieves pain. PAD, if left untreated, can progress to skin and muscle damage since the blood supply to these tissues has been compromised. In severe cases, surgery may be required to attempt to restore flow to the tissues. Unfortunately, amputation will sometimes be required. “Once diagnosed with PAD your risk for CAD, MI, CVA, and TIA is six to seven times greater than the risk for people who do not have PAD.” (Sutton, 2010, p. 262). Individuals with diabetes mellitus are predisposed to developing cerebrovascular accidents (CVA) due to the damage of vessels that supply the brain with oxygen and nutrients caused by hyperglycemia. These vessels have been damaged or narrowed by plaque formation. An ischemic CVA occurs when an artery that supplies the brain becomes blocked which suddenly decreases brain flow or completely stops blood flow resulting in an infarction. Ischemia can also be caused by a blood clot that has formed. Diabetics, especially type II individuals, tend to have high levels of fibrinogen, a protein necessary for clotting. High levels of fibrinogen, however, can cause excess blood clot formation. Hemorrhagic CVA’s are also possible. These occur when a blood vessel in the brain bursts and the leakage of blood spills onto brain tissue and impairs the ability of the neurons to function effectively. Diabetics, however, tend to have more ischemic CVAs. Transient Ischemic Attacks (TIAs) are referred to as “mini-strokes.” Diabetics are at high risk of developing TIAs. This disorder mimics a stroke but will resolve on its own with no lasting neurological deficit. TIAs may occur when a clot temporarily lodges in the brain, blocking blood flow but is then dislodged prior to any permanent damage occurring. A TIA is often a warning sign that a person is at risk for a CVA. “One third of patients diagnosed with TIAs will have an acute CVA in the future” (Sutton, 2010, p. 248). TIAs generally last only several minutes with most symptoms resolving within an hour. Signs of TIAs mimic CVAs which include: sudden numbness or weakness on one side of the body, facial droop, confusion or trouble speaking or understanding speech, blurred or blocked vision, difficulty walking, loss of balance and sudden severe headache. Coronary Artery Disease (CAD) is a condition where plaque builds up inside arteries. In diabetics, this is a direct result of persistent hyperglycemia. When coronary arteries are narrowed, there is an inadequate supply of oxygen rich blood flowing to the heart. A myocardial infarction (MI) occurs when blood flow to the heart muscle becomes blocked. If blood flow is not quickly restored, muscle is damaged and begins to die. Scar tissue forms and causes long-lasting complications that include heart failure and arrhythmias that can lead to sudden cardiac death. Heart failure is a condition characterized by ineffective pumping by the heart. The heart either cannot fill with enough blood or cannot pump the blood out effectively. This usually develops over time, as the pumping of the heart grows weaker. Right-sided heart failure occurs when the heart cannot effectively pump blood to the lungs to be oxygenated. Left sided heart failure occurs when the heart cannot pump oxygen rich blood to the body. The leading causes of heart failure are coronary artery disease, hypertension, and diabetes. Heart failure develops in diabetics due to persistent high glucose levels in the bloodstream that have weakened blood vessels around the heart. As the vessels become weaker, protein and other substances are released into the blood, having a toxic effect on the heart. Patient Education The education handout discussed in this section can be found at the following link: teaching patients about diabetes and how to adjust their life accordingly, there are many resources that are available to help guide the nurse and patient. The National Diabetes Education Program authored the handout. It is easy for patients to understand and does not use difficult terminology. The “SMOG” score of the handout was about an 8. There were 21 polysyllabic words in about 30 sentences. Taking the square root of 21, then adding 3, came to a little under 8. This suggests that the reading level of the handout is about eighth grade. It is important to recognize when reading material is appropriate and understandable for the patient. They are not nurses and do not know the same terminology and language as nurses do. The majority of patients will be able to read and learn from this handout. The first part of the handout goes over the different types of diabetes. Type one, which is when insulin isn’t produced by the body and insulin needs to be taken every day. Type two, the most common type of diabetes, is when the body doesn’t make or utilize insulin as efficiently as it should. With type two diabetes some people need to take insulin, but the majority of patients can control their diabetes with oral medication and lifestyle changes to their diet and activity level. The third and final type of diabetes is gestational diabetes, which is a type of diabetes that some women present with when pregnant. All though each type of diabetes is different, they require that the patient have regular doctor appointments, as well as other health care appointments (dentist, podiatrist, ophthalmologist, dietician, etc.)The handout educates patients about the ABC’s of diabetes. The “A” being the A1C blood test, which is a test that measures your average blood sugar levels over the last few months. The goal is for diabetics to generally have an A1C level below 7. The “B” is for blood pressure. It is often more difficult for diabetics to keep a normal blood pressure, but they should aim for a reading less than 140/80 mmHg. The “C” is for cholesterol (U.S. Department of Health and Human Services [DHHS], National Institutes of Health [NIH], & Centers for Disease Control and Prevention [CDC], National Diabetes Education Program, 2013). Everyone, including diabetics, need to monitor their cholesterol and adjust their exercise and diet accordingly.The handout discusses diet and exercise recommendations for a diabetic patient. The handout suggests walking 3 times a week for ten minutes each time. However, the USDA (2013) recommends that people do 30 minutes of moderate exercise 5 days a week, or 25 minutes of intense exercise 3 times a week. They too recommend lifting weights twice a week. When a patient is diabetic, they need to be careful when exercising and know their body. When people exercise they can become hypoglycemic. It is important to check blood sugar levels before and after and take insulin and eat a snack when needed.When teaching patients about prevention of illness or an illness that they may currently have, it is important to take into consideration the patient’s culture. Culture competent nursing plays an important role in patient education. A culturally competent nurse must develop cultural sensitivity. Facione (1993) defines cultural sensitivity as “an awareness and utilization of knowledge related to ethnicity, culture, gender, or sexual orientation in explaining and understanding situations and responses of individuals in their environment” (as cited in Chang, 2007). Patients from different cultures view illness differently and in order to properly educate patients, it is important that nurses take into consideration their views of illness, health care, medicine, language, etc. Not only do the nurses need to be able to convey their message to the patient, but also they need to do it appropriately and respectfully according to the patient’s culture. This is why it is important that a heath history and patient interview be done. Many cultures will perceive an illness such as diabetes differently. The handout is written in a way that people from many different cultures can benefit from the information. The handout is written in English and uses some English health terminology, which may be more difficult for someone who speaks another language other than English. In the United States, there is advanced medical technology and testing, whereas in other countries or cultures they may not have access to the same level of healthcare as the average middleclass American. The handout suggests the need for diabetics to go to several doctors, including dieticians, dentists, podiatrist, ophthalmologists, etc. For the average American that may be easy to do, but not everyone has access to healthcare. The handout could have gone into more detail about how to promote self-care in those areas and the ways that people can make sure they are properly taking care of their teeth, feet, diet, and eyes. Although this handout is written for the average American with diabetes, there is educational information in this handout for people from a variety of cultures to be able to benefit and learn from.ConclusionIn conclusion, Diabetes Mellitus is a devastating, chronic disease that has numerous harmful effects to the overall health and wellness of society. The pathophysiology is a complex imbalance of our body’s natural way of producing insulin and controlling blood glucose levels. For the layperson, DM can be confusing and difficult to understand. Statistics prove that this is not a problem that is going away on its own, and predicted to become more prevalent around the world. With comprehensive understanding of the disease process and the destructive nature of DM, health care providers can provide the needed prevention, education and management of this chronic disease. By providing information on the above topics, the authors of this group paper have met our goal of aiding healthcare providers in their responsibility to clients in the community.ReferencesAmerican Medical Association. (2008). Guide to preventing and treating heart disease. Hoboken, NJ: John Wiley & Sons, Inc.Blood Sugar: MedlinePlus. (2013). U.S National Library of Medicine. Retrieved from , M. & Kelly, A.N. (2007) Patient education: Addressing cultural diversity and health literacy issues. Urologic Nursing. 27. 411-417. Retrieved from Funnell, M. (2011). Know your blood sugar numbers. . Retrieved from , S. J. (Ed.). (2011). Health references series: Diabetic sourcebook (5th ed.). Detroit, MI: Omnigraphics, Inc.Kidney Disease (Nephropathy). (2013). American Diabetes Association. Retrieved from , S. L. (8th edition). (2011). Medical surgical nursing: Assessment and management of clinical problems). St. Louis, MO. Elsevier Mosby Mayo Clinic. (2009). The essential diabetes book. (2009). New York, NY: Time, Inc.Meetoo, D., & Allen, G. (2010). Understanding diabetes mellitus and its management: an overview. Nurse Prescribing, 8(7), 320-326.Norwood, P. (2011, August 8). USDA exercise guidelines. Retrieved from usda-aerobic-exercise-guidelines-ga.htm Sutton, A. L. (Ed.). (2010). Health reference series: Cardiovascular disorders sourcebook (4th ed.). Detroit, MI: Omnigraphics, Inc.Taylor, C.R. (2011). Fundamentals of nursing: The art and science of nursing care. Philadelphia, PA. Lippincott Williams and WilkinsTopiwala, S. (2012). Diabetes and kidney disease. Retrieved from . Department of Health and Human Services, National Institutes of Health, & Centers for Disease Control and Prevention, National Diabetes Education Program. (2013). 4 steps for managing your diabetes for life (NIH PublicationNo. 13-5492NDEP-67). Retrieved from NDEP67_4Steps_4c_508.pdf World Health Organization. (2013, October). Diabetes. Retrieved from ................
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