Diabetes: The Biggest Things a Nurse Should Know
Diabetes mellitus is a syndrome of disordered metabolism, usually due to a combination of hereditary and environmental causes, resulting in abnormally high blood sugar levels (hyperglycemia). What's the Difference Between Type I and Type II?TYPE IType 1 DM is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas, leading to a deficiency of insulin. This type can be further classified as immune-mediated or idiopathic. The majority of type 1 is of the immune-mediated variety, where beta cell loss is a T-cell mediated autoimmune attack. 
Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. Type 1 diabetes can affect children or adults but was traditionally termed "juvenile diabetes" because it represents a majority of the diabetes cases in children. The principal treatment of type 1 diabetes, even in its earliest stages, is replacement of insulin combined with careful monitoring of blood glucose levels using blood testing monitors. Without insulin, diabetic ketoacidosis often develops which may result in coma or death. Treatment emphasis is now also placed on lifestyle adjustments (diet and exercise) though these cannot reverse the progress of the disease. 
Apart from the common subcutaneous injections, it is also possible to deliver insulin by a pump, which allows continuous infusion of insulin 24 hours a day at preset levels, and the ability to program doses (a bolus) of insulin as needed at meal times. Non-insulin treatments, such as monoclonal antibodies and stem-cell based therapies, are effective in animal models but have not yet completed clinical trials in humans. Type II Type II diabetes mellitus is characterized differently due to insulin resistance or reduced insulin sensitivity, combined with relatively reduced, and sometimes absolute, insulin secretion. The defective responsiveness of body tissues to insulin almost certainly involves the insulin receptor in cell membranes. However, the specific defects are not known. 
The predominant abnormality in the early stage is reduced insulin sensitivity, which appears as elevated levels of insulin in the blood. At this stage hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver. As the disease progresses, therapeutic replacement of insulin often becomes necessary.
There are numerous theories as to the exact cause and mechanism in type 2 diabetes. Central obesity (fat concentrated around the waist in relation to abdominal organs, but not subcutaneous fat) is known to predispose individuals to insulin resistance. Abdominal fat is especially active hormonally, secreting a group of hormones called adipokines that may possibly impair glucose tolerance. 
Obesity is found in approximately 55% of patients diagnosed with type 2 diabetes. Other factors include aging and family history. Environmental exposures may contribute to recent increases in the rate of type 2 diabetes. A positive correlation has been found between the concentration in the urine of bisphenol A, a constituent of polycarbonate plastic, and the incidence of type 2 diabetes.
Type 2 diabetes may go unnoticed for years because visible symptoms are typically mild, non-existent or sporadic, and usually there are no ketoacidotic episodes. However, severe long-term complications can result, including renal failure due to diabetic nephropathy, vascular disease (including coronary artery disease), vision damage due to diabetic retinopathy, loss of sensation or pain due to diabetic neuropathy, liver damage from non-alcoholic steatohepatitis and heart failure from diabetic cardiomyopathy. Insulin: What's the Scoop?
Insulin is a hormone produced in the islets of Langerhans in the pancreas. It causes most of the body's cells to take up glucose from the blood, storing it as glycogen in the liver and muscle, and stops use of fat as an energy source. When insulin is absent (or low), glucose is not taken up by most body cells and the body begins to use fat as an energy source Insulin is used medically to treat some forms of diabetes mellitus. Patients with Type 1 depend on external insulin for their survival because the hormone is no longer produced internally. Patients with Type 2 diabetes mellitus are insulin resistant, have relatively low insulin production, or both. With disease progression, Type 2 patients may also end up using insulin. Common Types of Insulin: #1. Rapid-acting types are presently insulin analogs, such as the insulin analogs aspart or lispro. These begin to work within 5 to 15 minutes and are active for 3 to 4 hours. Most insulins form "clumps" which delay entry into the blood in active form; these analog insulins do not, but have normal insulin activity. Newer varieties are in now in Phase II clinical trials which are designed to work rapidly, but retain the same genetic structure as regular human insulin. #2. Short-acting, such as regular insulin – starts working within 30 minutes and is active about 5 to 8 hours. #3. Intermediate-acting, such as NPH, or semilente insulin – starts working in 1 to 3 hours and is active 16 to 24 hours. #4. Long-acting, such as ultralente insulin – starts working in 4 to 6 hours, and is active well beyond 32 hours. #5. Insulin glargine and Insulin detemir – both insulin analogs which start working within 1 to 2 hours and continue to be active, without major peaks or dips, for about 24 hours, although this varies in many individuals. #6. A mixture of NPH and regular insulin – starts working in 30 minutes and is active 16 to 24 hours. There are several variations with different proportions of the mixed insulins. #7. A mixture of Semilente and Ultralente (typically in the proportion 30% Semilente to 70% Ultralente), known as Lente, is typically active for an entire 24 hour period. Beef Lente, in particular, has a very 'flat' profile. The Nurse's RoleThe primary goal of effective diabetes management is maintenance of normal circulating blood sugar levels to prevent onset, arrest development, and reduce the severity of associated co morbid diseases including neuropathy, retinopathy, and cardiovascular disease. In pursuit of this goal, the health nurse, together with registered dietitians and registered pharmacists, serve as the cornerstone to support patient-centered education.By focusing on patient-centered goals and providing education and support for self-management measures, the health nurse assists the patient toward the primary goal of effective disease management and reduction of complications. The following simple mnemonic may help patients, families, and nurses alike to attend effectively to each area of self-management: 
W— weight control I— insulin management S— sick day management H— hyper/hypo symptoms and management M— maintenance of foot care O— 0 smoking! R— revving up of engines with activity/exercise E— eye care and follow-up evaluation. Diabetes and Nutrition: What Can You Eat?Why does it matter what I eat?What you eat is closely connected to the amount of sugar in your blood. The right food choices will help you control your blood sugar level. Do I have to follow a special diet? There isn't one "diabetes diet." Your doctor will probably suggest that you work with a registered dietitian to design a meal plan. A meal plan is a guide that tells you what kinds of food you can choose at meals and snack time and how much to have. For most people with diabetes (and those without, too), a healthy diet consists of 40% to 60% of calories from carbohydrates, 20% from protein and 30% or less from fat. Can I eat any sugar? Yes. In recent years, doctors have learned that eating some sugar doesn't usually cause problems for most people with diabetes--as long as it is part of a balanced diet. Just be careful about how much sugar you eat and try not to add sugar to foods. What kinds of foods can I eat? In general, at each meal you may have 2 to 5 choices (or up to 60 grams) of carbohydrates, 1 choice of protein and a certain amount of fat. Talk to your doctor or dietitian for specific advice. 
Carbohydrates: Carbohydrates are found in fruits, vegetables, beans, dairy foods and starchy foods such as breads. Try to have fresh fruits rather than canned fruits (unless they are packed in water or their own juice), fruit juices or dried fruit. You may eat fresh vegetables and frozen or canned vegetables. Condiments such as nonfat mayonnaise, ketchup and mustard are also carbohydrates.Protein: Protein is found in meat, poultry, fish, dairy products, beans and some vegetables. Try to eat poultry and fish more often than red meat. Don't eat poultry skin, and trim extra fat from all meat. Choose nonfat or reduced-fat dairy products such as cheeses and yogurts. Fat: Butter, margarine, lard and oils add fat to food. Fat is also in many dairy and meat products. Try to avoid fried foods, mayonnaise-based dishes (unless they are made with fat-free mayo), egg yolks, bacon and high-fat dairy products. Your doctor or dietitian will tell you how many grams of fat you may eat each day. When eating fat-free versions of foods (like mayonnaise and butter), check the label to see how many grams of carbohydrates they contain. Keep in mind that these products often have added sugar. Carb CountingWhen people think of diabetes, one of the first associations that comes to mind is food, and especially the old prohibition against eating sweets. In fact, today's dietary guidelines are not as stringent, but are slightly more complex. The guidelines are:1.Eat a variety of healthy, nutritious foods 2.Reduce fat and protein to reasonable amounts 3.Balance carbohydrate with insulin and exercise. 
Maintaining this balance is what carb counting is all about. Over 90% of the carbs derived from starches and sugars end up as glucose that moves through the blood to your cells. Half the day's insulin is used to balance the carbohydrate we eat in foods. The other half meets the background insulin need, and this need remains relatively steady from day to day. Carb counting is well worth the effort to learn when you consider the impact it has on your control. To learn how to carb count effectively, you need to: - know what carbs are - know what grams are - know the 500 Rule - know how to count carbs - know how many carbs you need - practice, practice and practice some more Glycemic IndexThe Glycemic index (also glycaemic index) or GI is a measure of the effects of carbohydrates on blood glucose levels. Carbohydrates that break down rapidly during digestion releasing glucose rapidly into the bloodstream have a high GI; carbohydrates that break down slowly, releasing glucose gradually into the bloodstream, have a low GI. For most people, foods with a low GI have significant health benefits.
A lower glycemic index suggests slower rates of digestion and absorption of the sugars and starches in the foods and may also indicate greater extraction from the liver and periphery of the products of carbohydrate digestion. A lower glycemic response is often thought to equate to a lower insulin demand, better long-term blood glucose control and a reduction in blood lipids.
References Used: American Diabetes Association DM and Wikipedia Nursing Center Family Doctor - Diabetes: What the Diagnosis Means"
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