Advanced Theoretical concepts in Nursing

Diabetes Mellitus Type-II

By Talat Rashid December 12, 2007

Objectives
Define the disease in the case study Discuss the prevalence, significance of Diabetes Mellitus type II.(DM II) Describe the etiology, normal and altered pathology, and s/s of DM II Explain the prevention/complications of DM II Review the pharmacological manag. of DM II Discuss nursing management of DM II by incorporating the appropriate theory.

Case study
47 yrs old, father. Appeared in Diabetes consultant clinic on 29-11-07 Presenting features (from last 04 months) - Sense of heaviness over lower abdomen - Retention of urine - Excessive urination (Polyuria) - Excessive thirst (Polydipsia) - Excessive eating (Polyphagia) - Becomes angry on minor issues

cont
Family Hx: DM (-), HTN (+), Cardiac dis (+)

Personal/social Hx: Businessman, normal sleep, Appetite, feels has lost wt from 01 yr., smoking from last 10 yrs

Vitals
B.P 125/80 mmHg Pulse: 80/min (regular) RR: 22/min (unlabored) Wt 85 kg Ht: 180 cm Pain score: 1(on pain scale of 1-10) Allergies: Not known

General appearance
An adult man with average built walked in comfortably into the CC (accompanied by his wife) and sit on the chair with ease. Oriented to time, place and person, has clear speech & relevant talk but seems to have attention & eye contact during history taking and gives incomplete answers occasionally, looks depressed. Is well groomed and hydrated.

Physical Examination
Ht 180cm Wt 85kgs Body Mass Index (BMI) BMI = Wt (kgs) / Ht (mxm) = 85 kgs /1.8m x1.8m = 85 / 3.24 = 26.23kgs/m2 (n.range= 19-24kgs/m2) Overweight

Review of systems
Skin: inspection for breakdown, non healing pustules, diabetic ulcer or wound, Diabetic foot.

Neurological system: Sensory & motor system. Paralysis, Balance, response to pain & sensitization of hot or cold application over limbs for parasthesia to rule out Diabetic Neuropathy,
Cognition status: orientation, alertness, memory status. Eyes: vision, pain, cataracts, fundoscopy to rule out Diabetic Retinopathy

Mouth: inspection of gums & teeth for infection, buccal mucosa for
sores,

Cont.
CVS: pain, palpitation, heart sounds, dysnea, murmurs,, HTN

PVS: varicose veins, thrombophlebitis, leg cramps Genito-urinary : frequency of micturation, pressure symtoms, burning micturation, incontinence of urine, Diabetic Nephropathy

Musculoskeletal system : ROMs, strength, gait & balance

Endocrine : Goiter, change in weight, polyphagia, polidypsia, polyuria, glycosuria

Differential Diagnosis
Diabetes Mellitus Type II Diabetes Mellitus Type I Hyperlipidemia UTI BPH Anxiety

 FBS 134 mg/dl RBS 213 mg/dl Lipid Profile T. Cholesterol 201 mg/dl (Nor < 250) Triglycerides 104 mg/dl (Nor < 150) HDL 40 mg/dl (Nor > 40) LDL 143 mg/dl (Nor > 100)

Investigations

 DIABETES MELLITUS TYPE II (Non Insulin Dependant Diabetes Mellitus)

Definition
Type II diabetes is a chronic, common, complex metabolic disorder characterized by hyperglycemias, a disease of growing public health concern

Significance
INCIDENCE PREVENTABLE COMPLICATIONS COMORBIDS

HOSPITAL / TERTIARY CARE

HOSPITAL WORKLOAD / NOSOCOMIAL INFECTIONS NATIONAL ECONOMY HEALTHY AND PRODUCTIVE COMMUNITY

Prevalence
2.9 million people globally died of diabetes in 2000, about three times its previous estimate. WHO (2005) 200 million cases worldwide (Report of a WHO Meeting, 2004 )

 Prevalence in United States 20.8 million (7 % population) had diabetes in 2005, 6.2 million of them undiagnosed. 90 to 95 % (18.7 million - 19.8 million people) of Diabetics had type 2 diabetes. (U.S. National Institutes of Health-2006) Prevalence in Pakistan The prevalence rate of diabetes 16.2% (9% known and 7.2% newly diagnosed) in men and 11.7% (6.3% known and 5.3% newly diagnosed) in women. The prevalence increased to almost 30% and 21% in 65-74 years old men and women respectively. 79% of Diabetic men & 96% of Diabetic womenin Pakistan are obese. (Javed, 2003)

Incidence
Age Traditionally thought to affect > 40 years However, Incidence increasing in younger persons, in prepubertal children, teenagers, and young adults. Type 2 diabetes mellitus is observed even in some obese children. Sex; more common in women

Background
Unlike type 1 diabetes mellitus, patients are not absolutely dependent upon insulin for life, even though many of these patients are ultimately treated with insulin. Many people do not realize that they are suffering from type 2 diabetes as they experience symptoms of fatigue, lethargy, extreme thirst, frequent urination, susceptibility to infections and vision changes over a prolonged period of time. Being overweight can keep your body from making and using insulin properly. It can also cause high blood pressure

Endocrine system
Endocrine glands release hormones (chemical messengers) into the bloodstream to be transported to various organs and tissues throughout the body.The pancreas secretes insulin, which allows the body to regulate levels of sugar in the blood.

www.medline.medicine

Pancreas
The pancreas is located behind the liver and is where the hormone insulin is produced. Insulin is used by the body to store and utilize glucose.

www.medline.medicine

Islets of Langerhans
Islets of Langerhans contain beta cells and are located within the pancreas. Beta cells produce insulin which is needed to metabolize glucose within the body.

www.medline.medicine

Role of Insulin
Food intake containing CHO
End product of CHO metabolism GLUCOSE

Insulin is released Glucose in the blood

Movement of glucose to bodys muscle, fat & liver cells

Glucose used by the body as FUEL for ENERGY

Path physiology
Production of Insulin (Auto immune) Insulin resistance by liver, fat & muscle cells

Ineffective movement of Glucose to the cell

no energy available to cells

Blood Levels of Glucose

Hyperglycemia

Etiology
Presumably, the defects of type 2 diabetes mellitus occur when a diabetogenic lifestyle (ie, excessive calories a high-fat diet, inadequate caloric expenditure, obesity) is superimposed upon a susceptible genotype appears to cause type 2 diabetes mellitus.

Diabetes mellitus may be caused by other conditions. Secondary diabetes may occur in patients taking glucocorticoids or when patients have conditions that antagonize the actions of insulin (eg, Cushing syndrome, acromegaly, pheochromocytoma).

Risk factors of DM
A parent, brother, or sister with diabetes Obesity ( fat cells become insulin resistant) Age greater than 45 years Gestational diabetes or delivering a baby weighing more than 9 pounds High blood pressure High blood levels of triglycerides (a type of fat molecule) High blood cholesterol level Not getting enough exercise

Cardinal characteristics of DM
Hyperglycemia. Abnormally high glucose. Left untreated to coma or death.

Hypoglycemia. Abnormally low glucose. Left untreated convulsions, unconsciousness or brain damage.

COMPLICATIONS
Microvascular Diabetic Neuropathy eg; parasthesias and foot problems limb amputations Diabetic retinopathy eg; glaucoma, cataracts, macular degeneration and blindness).
.

Macrovascular Coronary, peripheral- vascular, diabetic nephropathy associated with BP & albumin in the urine (detected by urinalysis) kidney failure Others Skin disorders and infections. The stomach disorder Sexual dysfunction.. Urinary incontinence Gum disease

Arteriosclerosis of extremities
Arteriosclerosis of the extremities is a disease of the blood vessels characterized by narrowing and hardening of the arteries that supply the legs and feet. This causes a decrease in blood flow that can injure nerves and other tissues.
www.medline.medicine

Diabetic retinopathy
Excessive amount of glucose in the blood stream may cause damage to the blood vessels. Within the eye the damaged vessels may leak blood and fluid into the surrounding tissues and cause vision problems.

www.medline.medicine

Diabetic nephropathy
Uncontrolled diabetes causes thickening and hardening of the internal kidney structures. A kidney biopsy clearly shows diabetic nephropathy.

www.medline.medicine

Symptoms of DM II
3 Ps Polydypsia (Increased thirst) Polyuria (Increased urination) Polyphagia (Increased appetite) Fatigue Blurred vision Slow-healing infections Impotence in men Mood changes Sudden reduction in wt

Diagnostic criteria of DM II
The criteria adopted for the diagnosis of diabetes & most commonly used is The American Diabetes Association (1997) :

1. Fasting plasma glucose (FPG) >126 mg/dL on 2 occasions or random plasma glucose (RPG) > 200 m g/dl 2. Classic symptoms of diabetes mellitus (ie, polyuria, polydipsia, polyphagia, weight loss).

Cont..
Oral glucose tolerance test is +ive if glucose level is >/= 200 mg/dL a/f 2 hrs of intake. Hemoglobin A1c (HbA1c) level >7% is a measure of average blood glucose during the previous 2 to 3 months. It is a very helpful way to determine how well treatment is working. High triglycerides (>250 mg/dL) or low HDL (<35 mg/dL).

Treatment of DM II
Oral antidiabetics *Tab Amaryl Img Bid *Tab Glucobay 50mg BD Tab Diabenese 100mg, 250mg Tab Metformin 500mg OD Tab Glucophage 500mg OD Prophylactic drugs *Tab Esso 40 mg OD *Tab Ascard 70 mg OD

Tab Amaryl (Glymeperide)1,2&4mg

Action unknown, glucose possibly by stimulating release of insulin from functioning pancreatic beta cells. May sensitivity of peripheral tissue to insulin. Nsg considerations: -Watch for hypoglycemia (cautiously used in elderly & malnourished) -Drug should be taken with first meal of the day

Tab Glucobay (Acarbose) 25,50 &100mg

Alpha glycosidase inhibitor that delays digestion of CHO, resulting in a smaller rise in glucose level a/f meal Nsg considerations: -Watch for hypoglycemia -Contraindicated in inflammatory bowel disease, colonic ulceration, predispositon to intestinal obstruction.

Tab Ascard( Aspirin)70mg OD Salicylate

Reduces risk of recurrent transient Ischemic attacks & stroke in patients at risk, by impeding clotting by blocking prostaglandin synthesis, which prevent formation of platelet aggregation substance Thromboxone A2.

Nsg considerations - Use cautiously in pts with GI lesions, impaired renal function, Vit k deficiency, bleeding disorders. -Should be discontinued , if bleeding from any sight occurs & 7 days prior surgery - Pt taught to take drug with food

Cont
Research in the proposed treatment of type II diabetes : Replacement hormones, such as glucagon-like peptide-1 (GLP-1). Pancreatic cell transplant, (the insulin producing cells will be transferred to a diabetic person to achieve a cure) Bariatric surgery (Christine 2005)

Complications
Heart attack Stroke Renal failure Limb amputation

Prevention
Exercise Normal weight control. Physical activity Healthy diet Strict blood glucose control

Integration of Theory in patient with DM Banduras Self-Efficacy Theory

Model of triade resiprocality

Background of theory
Self-Efficacy theory is an important component of Banduras social cognitive theory (1986), which suggests high interrelation b/w individuals Behavior, Environment and Personal ( cognitive, affective, & biological events) factors. (Graham & Winner, 1996)

Assumptions
The reciprocal nature of the determinants of human functioning in social cognitive theory makes it possible for therapeutic & counseling efforts to be directed at personal, environmental or Behavioral factors. Hence strategies for well-being can be aimed at improving emotional, cognitive, or motivational processes, increasing behavioral competencies, or altering the social conditions under which people live & work.

Cont..
Self-efficacy beliefs provide the foundation for human motivation, well-being and personal accomplishment. People who regard themselves as highly efficacious act, think & feel differently from those who perceive themselves as inefficacious. Because individuals operate collectively as well as individually, self- efficacy is both a personal & social construct.

Self-Efficacy

Self-efficacy is the belief in ones effectiveness in performing specific tasks. (Bandura, 1986)

Self efficacy in DM type II

Self- monitoring of Blood glucose, Compliance with Rx Follow Dietary restriction. Control weight Regular exercise. Regular follow ups in cc. Health outcome (improved health)

Develop habits of positive thinking, willingness to do Actions and self-reflection

Treatment Nurse Health Educator. Persuader Counselor Family HEALH CARE PROGRAMS

Nursing diagnosis
Fear r/t diagnosis of chronic illness Knowledge deficit r/t control of disease/ prevention of complications. Risk of ineffective coping r/t chronic disease Risk of noncompliance r/t the complexity of the prescribed regime and follow up.

Nsg interventions
Explain to the patient that the disease is controllable and the symptoms can be reduced by improving behaviors like: -Control on weight through a weight reduction program and exercise. Use of stairs instead of elevators, and a regular program of walk, starting from small distance to gradually increasing the distance. -Reduction of calories in diet. Limit fat intake to about 25 percent of total calories. For example, if the food choices add up to about 2,000 calories a day, should eat no more than 56 grams of fat. -Diet can be planed with the dietition. The patient can be asked to check food labels for fat content too.

Cont..
Avoid taking saturated fats coming from animals meats & dairy products like milk, cheese and ice cream; and in some kinds of cooking oils. Reduce serving sizes of foods (such as meat, desserts, and foods high in fat). Increase the amount of fruits and vegetables in the diet. Controlling carbohydrates in diet, such as: pasta, bread, rice, potatoes

Cont.
The patient is allowed to choose activities he/she enjoys. Some ways to work extra activity into daily routine: Take the stairs rather than an elevator or escalator. Park at the far end of the plot and walk. Get off the bus a few steps early and walk the rest of the way. Walk or ride bicycle instead of drive whenever he/she can.

Cont.
Compliance with Rx. The medicine must be taken as prescribed by the physician, at the right time in the right dose. Regular follow ups in cc, once in three months, with raflo checks and lipid profile and review of risk of appearance of 3 cardinal pathies.

Acknowledgements
Miss Salma Jaffer Ms Saleema Moiz Ms Zubaida ( Diabetic cc nurse) All Collegues

References
Anne.J., Diabetes Causes and Prevention, retrieved from http://www.a1articles.com on 9/12/2007 Author: Bandura.A. (1986), Social foundation of thought and action: a social cognitive theory, England cliffs NJ, Prentice Hall Diabetic diet information, what should you eat,retr. From http://www.a1articles.com on 7/12/2007 Pajares F., Overview of Social Cognitive Theory And of Self-Efficacy, retrieved from www.healthology.com on 7/12/2007 Porth, C. M. (2004). Pathophysiology: Concepts of altered health states (7th ed.). New York: Lippincott.