Med-Surg Endocrine System part 18: Diabetes Mellitus
In this article, we give an overview of one of the most common diseases in America — diabetes mellitus.
In nursing school, you will get lots of questions about diabetes on your nursing exams, especially Med-Surg. And as a practicing nurse, you will be taking care of many patients with diabetes. Because of the countless comorbidities it causes, people with diabetes are hospitalized more than others. It’s crucial to understand diabetes inside and out so you can properly care for your patients and educate them.
In this article, we’ll explain the differences between type 1 and type 2 diabetes, the pathophysiology, risk factors, symptoms, diagnosis and treatment options. This disease is covered in our Medical-Surgical Flashcards (Endocrine system).
Definition of diabetes
Diabetes causes chronic hyperglycemia (increased blood sugar levels) due to EITHER: insufficient insulin production by the pancreas, or insulin resistance of the cells in the body.
If you remember from our insulin overview earlier in this series, insulin’s job is to transport glucose from the bloodstream into the body’s cells where it can be used for energy.
This is another classic example of the endocrine system’s attempt to reach homeostasis in the body via a negative feedback loop: when the body senses that blood glucose levels are rising, the beta cells in the pancreas (islets of Langerhans) release insulin to help bring that glucose down.
You can think of insulin as an escort, helping to bring glucose from the bloodstream into the cells. Some students also find it useful to think of insulin as a key. Insulin acts like a key by opening the doors of the cells so glucose can enter. If you don’t have an escort, you can’t find your seat, and if you don’t have your keys, you can’t get in the door. If there’s not enough insulin, then glucose can’t get into the cells to be used for energy, and it builds up in the bloodstream
Types of diabetes
Type 1 diabetes
In type 1 diabetes, an autoimmune dysfunction destroys beta cells in the pancreas, and this leads to a lack of insulin secretion by the pancreas. Patients with type 1 diabetes are insulin dependent and will require insulin for the rest of their lives in order for the glucose to get from their bloodstream into the cells.
Type 1 diabetes used to be known as juvenile diabetes because it is most often discovered in children, but it was renamed because it can strike adults too.
Type 2 diabetes
In type 2 diabetes, we see progressive insulin resistance and decreased insulin production from the pancreas. Progressive insulin resistance means that insulin’s effectiveness at transporting glucose decreases over time — insulin becomes less effective. This usually occurs in adults, but there have been increasing cases of children with type 2 diabetes.
Note: Cathy uses the phrase “juvenile diabetes” in this video when she refers to childhood-onset type 2 diabetes, not the former name for type 1 diabetes.
The risk factors that are associated with type 2 diabetes are: obesity, inactivity, hypertension, hyperlipidemia (high cholesterol), smoking, genetics, and race and ethnicity.
Patients who are Black, Latino, or Native American are statistically at a higher risk for diabetes. It is important to note the word statistically. Race does not play a biologically predetermined role in this disease, but the risks are higher statistically for communities of color for a variety of reasons, including the social and environmental determinants of health — financial resources; access to adequate and nondiscriminatory health care; access to education; and more.
Gestational diabetes occurs when the placental hormones during a pregnancy counteract insulin, and this results in glucose intolerance during pregnancy.
Signs and symptoms of diabetes
The most notable and memorable signs and symptoms of diabetes are known as The Three Ps: polydipsia, polyphagia, and polyuria. Poly means multiple or many, dipsia is thirst, phagia is hunger, and uria means urine. This prefix and these root words are covered in our Medical Terminology flashcards, which we designed to equip you with the ability to translate any unfamiliar medical term you encounter!
Other symptoms of diabetes include:
- Weight loss. Although patients experience excessive hunger, they still lose weight because without insulin, the food they’re eating doesn’t enter the cells and they are basically starving even though they are eating.
- Warm skin
- Dehydration, which also causes:
- Dry skin
- Weak pulses
- Decreased skin turgor (skin is not elastic, when you pinch the skin and release it stays pinched and does not snap back in place)
- Fruity-smelling breath (that’s the glucose!)
- Kussmaul respirations (increased rate and depth of respirations) are seen in Diabetic Ketoacidosis (DKA) as a compensatory mechanism to attempt to correct metabolic acidosis by blowing off excess carbon dioxide.
- Nausea and vomiting
Remember from our prior video that blood glucose lab values, especially as they pertain to diabetes, are VERY important to know for your Med-Surg exams and in nursing practice. If a patient has two or more of the following labs on separate days, then that can indicate diabetes:
- Casual blood glucose over 200.This test measures blood sugar regardless of when the patient last ate, and it’s also sometimes known as a random blood sugar test. This test can be useful because blood glucose levels in non-diabetic don’t vary that wildly throughout the day, so amounts that vary wildly can indicate a problem.
- Fasting blood glucose over 126.This test is useful to get a baseline of what a patient’s glucose is when their body is not digesting anything, and is usually done first thing in the morning.
- Glucose over 200 with an oral glucose tolerance test (OGTT).The OGTT measures the patient’s blood sugar level initially, they are given a glucose solution to drink, and then the blood sugar is measured again (sometimes multiple times). The point of this test is to see how the body processes sugar in real time.
- HgB A1c over 6.5%.This test gives a longer term picture, kind of like the drug tests that are done on hair follicles! This test measures the patient’s average blood sugar level for the past two to three months. It’s actually measuring what percentage of your hemoglobin is coated with sugar
The treatment for Type 1 diabetes is insulin. If your patient has type 1 diabetes, they will need that insulin for the rest of their life since their pancreas does not make enough. If your patient has type 2 diabetes, they may require insulin, but they will likely begin treatment with oral antidiabetic medications.
These oral antidiabetics aren’t insulin replacements; they are more like insulin encouragers. This means that these medications don’t work for type 1 diabetics, because their insulin cannot be encouraged. They simply can’t make it, and require outside insulin.
When you treat diabetes, the goal is to get the Hgb A1c under 7%.
Foot care is very important for diabetic patients. Cathy, as a wound nurse herself, has seen many diabetic foot ulcers that have unfortunately led to amputations.
The feet of a diabetic patient can be injured easily for several reasons. Diabetes can cause neuropathy that prevents the patient from feeling sensation in their feet. Because we walk around all day, feet are more at risk than other body parts of being injured, and without sensation, you don’t feel pain when injured, so you may be carrying on with an injured foot and not know it! Think about it: if you were to step on a nail, you’d want to know about it immediately!
The second reason is that diabetes can cause reduced blood flow to the feet, which makes it harder for injuries or infections to heal. So if this patient does injure their feet, it takes a lot longer to heal.
Here is some foot care teaching you want to provide your diabetic patient:
- Patients should inspect their feet daily using a mirror,
- Check their shoes for objects before putting their feet in,
- Apply moisturizer to combat dry skin, but not between the toes because it can result in Athlete’s foot (a fungal infection),
- Wear cotton socks as opposed to synthetic socks,
- Wear closed-toe shoes to protect against injuries (think of it as a helmet for your feet!),
- Avoid hangnails and the resulting infections by cutting toenails straight across rather than rounding,
- Don't use over-the-counter products for corn or callus removal,
- Avoid using heating pads on their feet, as they might not be able to feel it if it was burning them.
When patients with diabetes get sick, they are much more likely to have life-threatening complications, like diabetic ketoacidosis (DKA). Here are some special instructions to provide your patient about caring for themselves when they are sick:
- Monitor their blood glucose levels more frequently
- Don’t skip insulin
- Test their urine for ketones, which are an indicator of DKA
- Drink 3L water per day to avoid dehydration
- Notify their provider if:
- Illness lasts for more than 1 day
- Temperature over 101.5℉ or 38.6℃
- Blood glucose over 250
- Urine positive for ketones
In our next article, we will cover complications associated with diabetes!
Cathy’s teaching on these disorders is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.
In this video, we are going to talk about diabetes mellitus, and this is a super-important topic. If you're in nursing school, you will definitely be asked lots of questions about diabetes on your nursing exams. And then as a practicing nurse, you will be taking care of many patients with diabetes, in all likelihood. So diabetes has a lot of different comorbidities that it causes, so individuals with diabetes are hospitalized more than other people. So it's important to understand this disease inside and out so that you can properly care for your patients and educate them.
So in this video, we are going to talk about the pathophysiology of diabetes. We're going to talk about risk factors as well as signs and symptoms, labs, and diagnosis of diabetes, as well as foot care and illness care.
Diabetes causes chronic hyperglycemia, so increased blood glucose levels, due to insufficient insulin production by the pancreas and/or insulin resistance of the cells in the body. So insulin is kind of like an escort, and it helps to bring glucose from the bloodstream into the cells. So if there's not enough insulin, then glucose can't get it to the cells and it builds up in the bloodstream.
So there are three types of diabetes, type 1, type 2, and gestational diabetes.
With type 1, we have destruction of the beta cells in the pancreas due to an autoimmune dysfunction, and this leads to a lack of insulin secretion by the pancreas. So patients with type 1 diabetes, they are insulin dependent. They will require insulin for the rest of their lives in order for that glucose to get from the bloodstream into the cells.
Then we have type 2 diabetes. This is where we have progressive insulin resistance and decreased insulin production from the pancreas. And this typically occurs later in life, but not always. So we definitely are seeing increased incidences of juvenile diabetes.
Risk factors associated with type 2 diabetes includes obesity, inactivity, hypertension, hyperlipidemia, smoking, genetics, and race. So patients that are African American, Hispanic, or American Indian, they are definitely at higher risk for diabetes.
The third type of diabetes is gestational diabetes. So this is where the placental hormones counteract insulin, and this results in glucose intolerance during pregnancy.
Alright. Now, let's talk about the signs and symptoms of diabetes, which are basically the signs and symptoms of hyperglycemia. There's a lot to remember but they're all here on the back of card 44 [of the Endocrine system section in the Medical-Surgical Flashcard deck].
Let's first talk about the three P's, polydipsia, polyphagia, and polyuria. Poly means a lot or many. So with diabetes, we're going to have a lot of thirst, a lot of hunger, and a lot of urine.
Other symptoms include weight loss, warm and dry skin. So the way I remember the skin symptom is, "Warm and dry, sugar's high. Cold and clammy, needs some candy." So we'll talk about that cold and clammy skin when we cover hypoglycemia, but for hyperglycemia, the skin will be warm and dry.
Other symptoms include dehydration - which you may see weak pulses and decreased skin turgor in a patient with dehydration - fruity breath, Kussmaul respirations.
So with Kussmaul respirations, we have increased rate and depth of respirations. Other signs and symptoms include nausea and vomiting, weakness, and lethargy.
So in terms of diagnosis of diabetes, if the patient has two or more of the following labs on separate days, then that is indicative of diabetes. So these labs include a casual blood glucose over 200, a fasting blood glucose over 126, glucose over 200 with an oral glucose tolerance test or an Hgb A1c over 6.5%. So again, if they have two or more of those over separate days, then they would be diagnosed with diabetes.
In terms of treatment, insulin is definitely an important one to remember.
If your patient is type 1, that is all they're going to be getting, right? They're insulin dependent. Type 1 diabetic patients cannot take oral diabetic medications. They require insulin.
If your patient is type 2, they can take insulin, but they can also receive oral antidiabetic medications.
So when we are treating diabetes, our goal is to try to get the Hgb A1c under 7%. So that Hgb A1c result really tells us a lot about the patient's blood glucose levels over the past two, three months, as opposed to just doing a spot check on the blood glucose. It just tells you how that glucose is doing right then and there. That Hgb A1c is a more indicative result on how the patient has been managing their diabetes over the last several months. So that's going to be an important one to watch for, and our goal is to get that under 7%.
Alright. So finally, let's talk about foot care and illness care, which are some important teaching you'll need to provide your diabetic patient.
With foot care, as a wound nurse, I see lots and lots of diabetic foot ulcers that often lead to amputations. It's a huge complication of diabetes, so we need our diabetic patients to take care of their feet.
So some of the education you should provide your diabetic patients include that they need to inspect their feet daily. Using a mirror, they should always check their shoes for objects before putting their feet in there because that can cause damage.
They should apply moisturizer to their feet but not between the toes because putting it between the toes can result in athlete's foot, which is basically a fungal infection.
They should wear cotton socks, as opposed to synthetic socks, and they definitely need to wear closed-toe shoes. So they should not go barefoot or wear open-toed shoes, and their shoes need to be fitted properly. Ideally, they would go see their podiatrist and get some special properly-fitted shoes to help protect their feet.
They should cut their toe nails straight across. They shouldn't round them on the sides because that can cause hangnails, which can lead to really complicated infections.
They should also not use over-the-counter products for corn or callus removal.
And then finally, they should not use heating pads on their feet because diabetic patients have decreased sensation in their extremities. So if that heating pad is too hot, it can burn them and cause damage. And they won't even know because they can't really feel it.
In terms of illness care, this is definitely important. So I share an office with the diabetic educators at my hospital. And when patients get sick, they are much more likely to have life-threatening complications such as diabetic ketoacidosis, or DKA.
When your patient is sick, they need to monitor their blood glucose levels more frequently.
They should not skip insulin when they're sick.
And they also need to test their urine for ketones because if there is ketones in the urine, that could indicate that they have DKA.
Also, when the patient is sick, it's important to prevent dehydration. So they should drink about 3 liters of water per day to prevent that dehydration.
And then they should notify their provider if their illness lasts for more than one day, if they have a temperature over 38.6 degrees Celsius, if their blood glucose levels are over 250 or if their urine is positive for ketones.
Okay, so I know there's a lot of information in this video. I hope it's helpful. In my next video, we will go over complications and critical-care topics related to diabetes. Thank you so much for watching. If you have found value in these videos, be sure to like us, like the video, leave a comment. And be sure to subscribe as well to our channel. Thanks so much for watching!
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