Chronic Complications

Complications

• Chronic complications of diabetes mellitus result from consistently high glucose levels in the body.

• The longer the client has been diagnosed with diabetes, the greater the chance of developing one or more of these complications

• The complications are categorized as macrovascular disease and microvascular disease

Macrovascular Complications

• The macrocirculation (the large blood vessels) in people with diabetes undergoes changes due to atherosclerosis.

• Athersclerosis has an increased incidence and and earlier age of onset in people with diabetes

• Macrovascular complications include Coronary Artery Disease, Stroke and Peripheral Vascular Disease(PVD)

Atherosclerotic Coronary Heart Disease

• Is a major risk factor in the development of myocardial infarction in type2 diabetic.

• These patients have high cholesterol and triglyceride levels

• Coronary Heart Disease is the most common cause of death in people with type 2 diabetes.

• People who have a myocardial infarction are more prone to develop heart failure as a complication of the infarction

Stroke

• Stroke is 2 to 6 times more likely to occur in the type 2 diabetic

• Although the exact cause is unknown, hypertension plays a major role in its development

• The manifestations of impaired cerebral circulation are often similar to hypoglycemia or HHS and warrant immediate attention

PVD

• Occurs of the lower extremities and accompanies both types of DM, but the incidence is greater in type 2

• Diabetes-induced areriosclerosis of the lower legs is usually bilateral, develops at an earlier age, progresses more rapidly, and develops equally in men and women.

• Occlusions can form in the large vessels below the knee , causing impaired peripheral circulation

PVD Con’t.

• Decreased arterial circulation can lead to lower leg ulcers and gangrene

• **Gangrene from diabetes is the most common cause of nontraumatic amputations of the lower leg

PVD Manifestations

• Loss of hair on lower legs, feet, and toes• Atrophic skin changes: shininess and thinning• Cool to cold feet• Legs become red when dependent and white

when elevated• Thick toenails• Diminished or absent peripheral pulses• Intermittent claudication---pain with walking• Pain at rest, usually at night

Microvascular Complications

• Involves alterations in the microcirculation(the smaller blood vessels and capillaries)

• Organs most affected-the eyes, kidneys, and nerves

Diabetic Retinopathy

• Is the collective name for the destructive retinal changes that occur in the person with diabetes

• Changes in the retinal capillaries cause decreased blood flow to the retina, leading to retinal ischemia and possible retinal hemorrhage or detachment

• Retinopathy has 2 stages: nonproliferative and proliferative. Varying degrees of visual impairment can occur at any stage

Retinopathy Con’t.

• Retinopathy is the leading cause of blindness in people between the ages 20 and 74

• All diabetics have an increased risk for developing cataracts as a result of increased glucose levels within the lens. Yearly eye exams by an opthamologist are recommended for these clients

Diabetic Nephropathy

• Is a disease of the kidney characterized by increased levels of albumin in the urine, hypertension, edema, and progressive renal insufficiency

• This disorder is the most common cause of renal failure requiring dialysis or transplantation in the U.S.

• Nephropathy occurs in 20 to 30% of people with DM

Diabetic Nephropathy

• Changes in the glomerular capillaries in the kidneys result in glomerulosclerosis (fibrosis of the glomerular tissue)

• This condition severely impairs the filtering function of the glomerulus so that albumin is lost in the urine

• The first indication of nephropathy is microalbuminuria (small amounts of albumin in the urine).

Diabetic Nephropathy Con’t.

• With the presence of microalbuminuria, usually the client progresses to end stage renal disease or renal failure

• Because hypertension increases the progression of nephropathy, clients are treated with angiotensin-converting enzyme (ACE) drugs such as captopril

Diabetic Neuropathy (***DON’T CONFUSE WITH NEPHROPATHY)

• Involves disorders of the peripheral nerves and the autonomic nervous system

• Diabetic neuropathies cause one or more of the following problems:– Sensory or motor impairment– Postural hypotension– Delayed gastric emptying– Diarrhea– Impaired genitourinary function

Diabetic Neuropathy

• Neuropathies result from thickening of the capillary membrane and destruction of myelin sheath, which impairs nerve conduction

• Peripheral neuropathies are bilateral sensory disorders

• Manifestations first appear in the toes and feet and progress upward to involve the fingers and hands

Diabetic Neuropathy Con’t.

• Initial manifestations include distal paresthesia (a subjective feeling of numbness or tingling)

• Pain described as aching, burning, or shooting; and a feeling of cold feet

• People experience reduced feeling, touch, and position sense, increasing their risk for falls

• Foot injuries are common due to impaired temperature and pain sensation

Diabetic Neuropathy Con’t.

• There is no specific treatment for peripheral neuropathy

• Collaborative management focuses on controlling the neuropathic pain with antidepressants, neurontin, or a tropical cream-capsaicin

Autonomic Neuropathies

• Involve numerous organ systems including:– CARDIOVASCULAR-fixed, slightly rapid heart rate

and postual hypotension– GASTROINTESTINAL-delayed gastric emptying,

resulting in irregular blood glucose control, constipation, and diarrhea

– GENITOURINARY-neurogenic bladder(inability to empty bladder completely), leading to urinary retention and an increased risk of UTI’s and sexual dysfunction in men and women

The Diabetic Foot• People with Dm experience more problems with their

feet and subsequent amputations because of macrovascular disease, neuropathy, and infection

• Often, they experience some type of foot trauma without knowing it

• Because they have lost their perception of pain, an injury may go unattended for days or weeks

• Common sources of foot trauma are cracks and fissures caused by dry skin or infections such as athlete’s foot, blisters form ill fitting shoes, ingrown toenails, and direct trauma

Diabetic Foot Con’t• Foot lesions usually begin as a superficial injury,

then progress into an ulceration• In time the ulcer extends deeper into the muscles

and bone and can lead to abscess or osteomyelitis

• Infections commonly occur in the traumatized or ulcerated tissue

• Dry gangrene is manifested by cold, dry shriveled , and black tissues of the toes and feet

• If untreated, the whole foot eventually becomes gangrenous and requires amputation

Diabetic Foot Con’t.• Treatment consists of bed rest, antibiotics, and

debridement

• FOOT CARE GUIDELINES-Shoes that allow ½ to ¾ inch of toe room are best– Do not wear open-toed shoes, sandals, high heels, or

thongs– Buy shoes late in the afternoon when your feet are at

their largest– Buy shoes made of natural materials to allow for

perspiration to escape

Foot Care Guidelines Con’t.• Wear socks made of wool or cotton; no garters, knee

highs, or stockings• Wear insulated boots in the winter• Check the feet daily for red areas, cuts, blisters, corns,

calluses, or cracks. Pay close attention to in between the toes

• Check the skin for dry or damp areas• Use a mirror to check each sole and the back of each

heel• If you are unable to inspect your feet, have someone

do it for you

Foot Care Guidelines Con’t.• Cut toenails after washing, when they are softer and

easier to trim• Cut toenails straight across with a clipper, and smooth

edges and corners with an emery board• Do not use razor blades to trim toenails, or dry calluses• It is always best to have a podiatrist trim toenails• Never go barefoot• Do not use heating pads, hot water bottles, or ice

packs on the feet• Do not allow the feet to get sunburned• Do not put tape on the feet

INCREASED SUSCEPTIBILITY TO INFECTION

• The person with diabetes has an increased risk of developing frequent bacterial and fungal infections

• Normally, glucose is used efficiently throughout the body, but in people with diabetes, glucose accumulates in the epidermal layer of the skin

• Moisture tends to collect under the armpits, breasts, groin, or genitalia

Infection Con’t.

• The higher- than- normal concentration of glucose in the skin coupled with the moisture creates a perfect breeding area for microorganisms

• When the skin appears beefy red to violetred, an infection should be suspected

• Fungal infections can develop under the nails, giving them a thick, yellow, crumbly appearance

• Treatment focuses on prevention of infection

SPECIAL CONCERNS

• SICK-DAY MANAGEMENT-when the person with diabetes is sick, blood glucose levels increase, even though food intake decreases

• The person mistakenly alters or omits the insulin dose or oral antidiabetic agent, causing further problems

• Dietary guidelines during illness focus on preventing dehydration and providing adequate nutrition for promoting recovery

Nurse Teaching regarding Sick Days• Monitor blood glucose levels Q4H throughout the

illness• Test urine for ketones if blood glucose level is >250• Con’t to take the usual insulin dose or oral antidiabetic

agents as prescribed• Drink8 to 12 oz. of fluid each waking hour• Eat 10 to 15 grams of carbohydrates every 1 to 2 hours• Call your physician if unable to eat for more than 24

hours or if vomiting and diarrhea for more than 6 hours

Surgery Management

• Surgery is a stressor that releases excess counterregulatory hormones, causing hyperglycemia and insulin resistance

• Protein stores are decreased• Activity and diet patterns change, and medication

types and dosages vary• As a result, surgical clients with diabetes are at

greater risk for postoperative infection, delayed wound healing, fluid and electrolyte imbalances, hypoglycemia, and DKA

Surgery Management Con’t.

• For patients with type 2 DM, oral antidiabetic agents are usually withheld 1 to 2 days prior to surgery, and clients are given regular insulin

• Clients with type 1 DM follow a carefullt prescribed insulin regimen to meet their specific needs

• The surgical procedure should be scheduled for early in the morning to decrease the fasting time

Surgery Management Con’t.• If the patient is NPO post-op, IV dextrose is given along

with regular insulin every 6 hours. ***Although intake is decreased post-op, stress increases insulin requirements

• Regular blood glucose monitoring post-op is essential• If a patient with either type 1 or type 2 DM requires

total parental nutrition or enteral nutrition, the patient needs to be closely monitored for hyperglycemia because they both contain glucose. They often require increased insulin coverage.

Pancreas Transplant

• Involves replacing or transplanting the pancreas, pancreatic cells, or beta cells.

• Islet cell transplantation has had moderate success

• Researchers are investigating transplantation of the tail of the pancreas.

• Before clients can be considered transplant candidates, an extensive physical and emotional evaluation is done

Complementary Therapies

• Acupuncture may be used to relieve the chronic pain from peripheral neuropathy

• Before diabetics take any herbal supplements, they should talk with their health care provider. The following supplements may increase blood glucose levels: ginko biloba, glucosamine, and bee pollen. In contrast, basil, chromium, garlic and ginseng are herbal supplements that may reduce blood glucose levels.