Diabetes Mellitus Foot, Wagner II

Diabetes mellitus is a group of metabolic disorders characterized by elevated levels of blood glucose (hyperglycemia) resulting from defects in insulin production and secretion, decreased cellular response to insulin, or both. This leads to hyperglycemia, which may lead to acute metabolic complications, such as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Longterm hyperglycemia may contribute to chronic microvascular complications (kidney and eye disease) and neuropahtic complications. Diabetes is also associated with an increased occurrence of macrovascular disease, icluding coronay artery disease, (myocardial infarction), cerebrovascular disease (stroke) and peripheral vascular disease.

Types of Diabetes
Type 1 (Formerly Insulin-Dependent Diabetes Mellitus)
About 5%-10% of diabetic patients have type 1 diabetes. Beta cells of the pancreas that normally produce insulin are destroyed by an autoimmune process. Insulin injections are needed to control the blood glucose levels.
Type 1 diabetes has a sudden onset, usually before the age of 30 years.

Type 2 (Formerly Non-Insulin Dependent Diabetes Mellitus)
About 90% to 95% of diabetics have type 2 diabetes. It results from a decrease sensitivity to insulin (insulin resistance) or from a decreased amount of insulin production.
Type 2 diabetes is first treated with diet and exercise, then oral hypoglycemic agents as needed.
Type 2 diabetes occurs most frequently in patients older than 30 years of age and in obese patients.

Gestational Diabetes Mellitus
Gestational diabetes is characterized by any degree of glucose intolerance with onset during pregnancy (2nd or 3rd trimester).
It occurs in women 25 years of age or older, women younger than 25 years of age who are obese, women with a family history of diabetes in first-degree relatives, member of certain ethnical racial groups (eg, Hispanic Americans, Native Americans, or Pacific Islander). It increases their risk for hypertensive disorders of pregnancy.


Clinical Manifestations
Polyuria, polydipsia, and polyphagia
Fatigue and weakness, sudden vision changes, tingling or numbness in hands or
feet, dry skin, sores that heal slowly and recurrent infections.
Onset of type 1 diabetes may be associated with nausea, vomiting, or stomach pains.
Type 2 diabetes results from a slow (over years, progressive glucose intolerance and results in longterm complications if diabetes goes undetected fro many years (eg, eye disease, peripheral neuropathy, peripheral vascular disease). Complications may have developed before the actual diagnosis is made.
Signs and symptoms of DKA include abdominal pain, nausea, vomiting, hyperventilation, and a fruity breath odor. Untreated DKA may result in altered level of consciousness, coma, and death.

Assessment and Diagnostic Methods
High blood glucose levels: fasting plasma glucose levels 126 mg/dl or more, or random plasma glucose levels more than 200 mg/dl on more than one occasion.
Evaluation for complications.

Prevention
For obese patients (especially those with type 2 diabetes): weight loss is the key to treatment and major preventive factor for the development of diabetes.


Complications of Diabetes
Complications associated with both types of diabetes are classified as acute or chronic. Acute complications occur from short-term imbalances in blood glucose and include:
Hypoglycemia
DKA (Diabetic Ketoacidosis)
HHNS (Hyperglycemic Hyperosmolar Nonketotic Syndrome)
Chronic complications generally occur 10 to 15 years after the onset of diabetes mellitus. They include:
Macrovascular (large vessel) disease: affects coronary, peripheral vascular and cerebral vascular circulations.
Microvascular (small vessel) disease: affects the eyes (retinopathy) and kidneys (nephropathy); control blood glucose levels to delay or avoid onset of both microvascular and macrovascular complications.
Neuropathic disease: affects sensory motor and autonomic nerves and contributes to such problems as impotence or foot ulcers.


Gerontologic Considerations
Because the incidence of elevated blood glucose levels increases with advancing age, elderly adults should be advised that physical activity that is consistent and realistic is beneficial to those with diabetes. Advantages of exercise include a decrease in hyperglycemia, a general sense of well-being, metabolism of ingested calories, and weight reduction. Consider physical impairment from other chronic diseases when planning an exercise regimen for elderly diabetic patients.

Medical Management
The main goal of treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications. The therapeutic goal within each type of diabetes is to achieve normal blood glucose levels without hypoglycemia and without seriously disrupting patient’s usual activities. There are five components of management for diabetes: nutrition, exercise, monitoring, pharmacologic therapy and education.
Primary treatment of type 1 diabetes is insulin.
Primary treatment of type 2 diabetes is weight loss.
Exercise is important in enhancing the effectiveness of insulin.
Use oral hypoglycemic agents if diet and exercise are not successful in controlling blood glucose levels. Insulin injections may be used in acute situations.
Because treatment varies throughout course because of changes in lifestyle and physical and emotional status as well as advances in therapy, continuously assess and modify treatment plan as well as daily adjustments in therapy.
Education is needed for both patient and family.


Nutritional Management
Meal plan should be based on patient’s usual eating habits and lifestyle and should provide all essential food constituents (eg, vitamins and minerals).
Goals are to achieve and maintain ideal weight, meet energy needs, prevent wide daily fluctuations in blood glucose levels (keep as close to normal as is safe and practical), and decrease blood lipid levels, if elevated.
For patients who require insulin to help control blood glucose levels, consistency is required in maintaining calories and carbohydrates consumed at different meals.
Consult dietician for diabetes management planning to gradually increase or add fiber in meal plan (grains, vegetables).

Caloric Requirements
Determine basic caloric requirements, taking into consideration age, gender, body weight, and height and factoring in degree of activity.
Long-term weight reduction can be achieved by reducing basic caloric intake by 500 to 1,000 calories from calculated basic caloric requirements.


Teaching Patients About Self Care
Teach patient about proper foot care since diabetic patients are prone to development of wounds due to diminished sensation on the extremities.
Instruct patient not to submit self to pedicure or manicure because it can cause wound or abrasions that may heal solely and could predispose the client to development of infection.
Inform patient not to use any sharp objects in cleaning the nails on foot.
Instruct significant others to assess for temperature of hot items to be utilized by the patient to prevent burns or skin abrasions.
Nutrition
Initial education addresses the importance of consistency in eating habits, the relationship of food and insulin, and provision of individualized meal plan.
Teach patient to read food labels and adjusting meal for exercise, illness and special occasions.
Teach patients to read labels of “health” foods because they often contain sugar products (ie, brown sugar, honey, and corn syrup and may contain saturated vegetable fats, hydrogenated vegetable fats, or animal fats that may be contraindicated with elevated blood lipids.


Exercise
* Exercise is very important because of its effects on lowering blood glucose levels and reducing cardiovascular risk factors. Exercise is useful in losing weight, easing stress, and maintaining a feeling of well-being.
* Encourage patient to eat a 15-g carbohydrate snack (fruit exchange) or a snack of complex carbohydrates with protein before moderate exercise to prevent hypoglycemia.
* Warn patient about postexercise hypoglycemia, which occurs many hours after exercise.
* Discuss testing blood glucose before, during and after exercise and eating carbohydrate snacks to maintain blood glucose.
* Encourage regular exercise rather than sporadic exercise.
* Advise all patients with diabetes to discuss an exercise program with the physician.


Self-monitoring and Drug administration
* Teach patient self-monitoring of blood glucose levels. Instruct patient to keep a record of blood glucose test results.
* Teach patient on the administration of insulin and taking oral hypoglycemic agents.


Source: Johnson, J.Y., Handbook for Brunner and Suddharth’s Textbook of Medical-Surgical Nursing 10th edition.