DIAGNOSING & MANAGING DIABETES
DIAGNOSING DIABETES
Name five symptoms of diabetes/hyperglycemia.
Increased thirst, increased urination, fatigue, blurred vision, slow-healing infections
In order to diagnosis diabetes, when is the blood drawn to determine the fasting blood glucose level?
Collected after an 8 to 10 hour fast
If the symptoms of diabetes are present, but the blood glucose level from the above test is not very high, the oral glucose tolerance test may be required. What is involved in this test?
Involves a fasting glucose, followed by the patient drinking a standard amount of a glucose solution to “challenge” their system, followed by another glucose test two hours later.
Complete the charts below.
FASTING BLOOD GLUCOSE:
| Lab Result | Meaning |
| From _70__ to _109_ mg/dL(_3.9_ to __6.0_ mmol/L) | Normal glucose tolerance |
| From _110_ to _125_ mg/ dL(_6.1_ to __6.9_ mmol/L) | Impaired fasting glucose (pre-diabetes) |
| _126_ mg/dL ( _7.0_ mmol/L and above) | Probable diabetes |
ORAL GLUCOSE TOLERANCE TEST (2 hours after a 75-gram glucose drink)
| Lab Result | Meaning |
| Less than _140_ mg/dL (_7.8_mmol/L) | Normal glucose tolerance |
| From _140_ to _200_ mg/ dL(_7.8_ to __11.1__ mmol/L) | Impaired fasting glucose (pre-diabetes) |
| Over 200mg/dL (_11.1__ mmol/L) | Probable diabetes |
What is meant by “pre-diabetic” levels?
Higher than normal but lower than those defined as diabetic.
What are some reasons, other than pre-diabetes or diabetes, that a person may have elevated blood glucose levels?
Various diseases and conditions: acromegaly, acute stress, chronic renal failure, Cushing’s syndrome, medications (including corticosteroids, tricyclic antidepressants, diuretics, epinephrine, estrogens (birth control pills and hormone replacement), lithium, phenytoin (Dilantin, salicylates), excessive food intake, hyperthyroidism, pancreatic cancer, pancreatitis
SELF-MONITORING BLOOD GLUCOSE
How many times a day (range) are diabetics advised to test their own blood glucose levels (Self Monitoring Blood Glucose- SMBG), and what are typical times of day recommended for testing?
- 1-4 times a day
- Before meals
- 2 hours after a meal
- At bedtime
- At 3 a.m.
- Before an insulin reaction
- Anytime you sense that your blood glucose level is high
- More frequently on sick days
Complete the following chart regarding blood glucose level guidelines for SMBG:
| TIME: | EXCELLENT | GOOD | FAIR | POOR |
| Before a meal(or fasting) | 60-100mg/dL4.4-5.5mmol/L | 100-140 mg/dL5.5-7.7 | 140-180 mg/dL7.7-10.0 | over 180 mg/dLover 10.0 |
| After a meal | 110-140 mg/dL6.6-7.7 mmol/L | 140-180 mg/dL7.7-10.0 mmol/L | 180-220 mg/dL10.0-12.0 mmol/L | over 220 mg/dLover 12.0 mmol/L |
What are the 3 causes of fluctuations in blood sugar level?
Diet, exercise, insulin
What are some common reasons for blood sugar fluctuations?
- Changes in exercise or activity level
- Snacks added or omitted
- Delayed meals, or a change in the type of amount of food eaten
- Illness or infection
- Alcohol consumption
- Insulin injected into a lumpy area or an exercising arm or leg
- Over-treatment of an insulin reaction
- Skipped insulin injection
URINE GLUCOSE TESTING
Why isn’t simple urine testing used to determine glucose levels?
- You cannot test for low blood sugar (hypoglycemia) with urine testing.
- Sugar shows up in urine only when the blood glucose level exceeds the kidney threshold, and this threshold could be high.
- Because urine collects in the bladder over time, urine testing provides general information on blood glucose level over a few hours, rather than exact information on the level at test time.
Considering the drawbacks of urine testing, why would a doctor decide that this is the best option for some patients?
Urine testing is easy, painless, and inexpensive. And some people just can’t learn to draw a drop of blood.
What percentage range indicates a positive urine test?
1% to 5%
A negative urine test indicates that the blood glucose level is probably below
180mg/dl
INSULIN
What do the insulin test and the C-Peptide test monitor?
Monitor insulin production
What are signs of an allergic reaction to insulin (mild/generalized)?
Small, hard red area at the injection site, may itch…generalized>>hives and itchy skin over other parts of the body
Insulin edema may develop when insulin therapy is started, subsiding in a few weeks. What are the signs?
Swelling in the legs, ankles, feet, hands, or face
What is lipohypertrophy?
The formation of scar tissue in an area that has been used repeatedly for injection. A firm, lumpy area develops. Insulin absorption is changed in this area.
What is lipoatrophy, and why is the condition now rare?
Used to describe the “pitted” areas (loss of fat) that may form at injection sites. More prevalent with the use of impure insulins.
What happens to the blood glucose level when one has an insulin reaction?
Blood sugar may fall below 60mg/dl, or fall rapidly from a high level to a lower level, or simply fall below the patient’s usual level. (hypoglycemia)
What are common triggers of an insulin reaction (hypoglycemia)?
Injecting too much insulin, skipping a meal, eating too little, or waiting too long between meals, exercising or working more than usual
What are the symptoms of a mild hypoglycemia, and what should be done?
- Cold sweat and a clammy feeling
- Dizziness, weakness, or shakiness
- Irritability or impatience
- Pounding heart or increased heart rate
Consume juice or sugar.
What are the symptoms of moderate hypoglycemia, and what should be done?
- Nervousness or confusion
- Headache
- Blurred or double vision
- Hunger
- Numbness or tingling in lips of finger tips
Consume juice or sugar.
What are the symptoms of severe hypoglycemia?
- Paleness and slurred speech
- Bizarre behavior
- Convulsions
TESTING THE URINE FOR KETONES
At what blood glucose level would a doctor recommend the patient to test the urine for ketones, and in general, what do ketones in the urine signify?
200mg/dL; ketonuria signifies a low insulin level that requires quick action
HEMOGLOBIN (A1C) TEST
What is the glycosylated hemoglobin/ hemoglobin A1C test and why is it tested?
When red blood cells are exposed to glucose in the blood, glucose attaches itself to the hemoglobin in the red blood cells and forms glycolsylated hemoglobin in the blood. Since each red blood cell lives for 2-3 months in the blood stream, the amount of glycosylated hemoglobin in the blood gives an average of the blood sugar over the last 2-3 months. Therefore, the test monitors glucose control over a period of time.
A normal level on the glycosylated hemoglobin (A1C) test can result from what two situations?
1) very well controlled diabetes or 2) a combination of very high blood sugar at some times and very low blood sugar at other times resulting in that same average.
What is a good test result for the A1C test if you are a diabetic?
6% (0.6)
Each 1% decrease in A1C translates into a 35-40% decrease in the frequency of microvascular complaints.
DIAGNOSING & TREATING DISEASES ASSOCIATED WITH DIABETES
CARDIOVASCULAR DISEASES
To what does macrovascular disease refer? Briefly describe arterio/atherosclerosis.
Changes in the medium to large sized blood vessels. Arteriosclerosis-the blood vessel walls thicken and become hard and non-elastic. Atherosclerosis-blood vessels also become clogged with mounds of plaque. Eventually, the flow of blood may be blocked.
What blood pressure level is indicative of hypertension?
> or = 140/90 mmHg
Hypertension increases the risk of what related health problems for diabetics?
Cardiovascular disease, retinopathy, nephropathy
Epidemiological analyses show that high blood pressures are associated with increased cardiovascular event rates and mortality in people with diabetes.
What are the target lipid levels for diabetics?
LDL< 70 mg/d in moderate risk and<50mg/dl in high risk l; HDL>40 mg/d in men and> 50md/dl for women l; triglycerides<150 mg/dl.
Why is lipid management so important?
Reduce risk of cardiovascular disease.
What is peripheral vascular disease, and what symptoms result if blood flow is only partially interrupted versus completely interrupted?
PVD- diseased blood vessels that supply the legs and feet. Partial block- cramps, weakness, “charley horse,” pain in the legs when walking. Complete block- severe pain, legs will become cold and pale, ulceration possible
How is peripheral vascular disease treated?
Replacing the diseased artery surgically or opening the blood vessel by compressing plaque against the artery wall (angioplasty)
What is coronary artery disease, and what medical conditions result if blood flow is decreased versus completely blocked?
CAD- diseased heart arteries. Decreased flow- cramping and angina.
Complete block- myocardial infarction.
What are the symptoms of partial/complete blockage of coronary arteries? Symptoms: chest pressure, cramping, heavy feeling in the chest, shortness of breath, and extreme fatigue.
What are treatments of coronary artery disease?
Coronary bypass surgery and angioplasty/stenting.
What is cerebral vascular disease?
CVD- diseased arteries in the brain.
What is the medical phrase given to describe a reduction in blood flow due to a partial blockage in an artery of the brain?
transient ischemic attack
What causes complete loss of blood supply to an area of the brain, and what is the result?
Cause- clogging or breaking of a blood vessel; Result- cerebral vascular accident (stroke)
What are symptoms of a partial/complete blockage of cerebral arteries? Lightheadedness, dizziness, loss of ability to speak, slurred speech, confusion, and inappropriate behavior
KIDNEY DISEASE
What is microalbuminuria, and why is it a sign of diabetic nephropathy?
Low levels of the protein albumin leak into the urine, but this protein is normally removed from the urine by the kidneys.
Of what, other than nephropathy, is microalbuminuria a well-established marker?
Cardiovascular disease
What are normal levels of urine microalbumin?
<30mg/24 hours
What level is indicative of macroalbuminuria?
>300mg/day
What is creatinine and blood urea nitrogen (BUN), and why are blood tests for these administered to measure kidney function?
Creatinine is a metabolic byproduct of creatine, the acid that supplies energy for muscle contraction, and BUN is an end-product of protein metabolism formed in the liver. In healthy individuals, both urea and creatinine are filtered out of the bloodstream by the kidneys. Excessive amounts of either of these substances in the blood indicate renal impairment.
What is the reference range for BUN?
10-20mg/dL
What is the reference range for creatinine?
0.3-1.5 mg/dL
What are the signs and symptoms of kidney disease?
Blood and/or protein in the urine; high blood pressure; burning during urination; frequent urination, especially at night; puffiness and swelling around the eyes, hands, and feet; excessive itching; nausea and vomiting; weakness.
Name 3 treatments for kidney failure.
Hemodialysis, peritoneal dialysis, kidney transplants
What causes diabetic bladder dysfunction, and what further organ complications can result from this dysfunction?
Caused by damage to nerves of the bladder—results in incomplete emptying of the bladder. Bacteria grows in stagnant urine and travels up to the kidney and causes infection.
NEUROPATHY
Describe the various stages of treatment required for neuropathic ulcer.
Decrease pressure on feet, remove callus regularly, proper dressing, antibiotics if infected, rest, orthowedge—designed to reduce pressure at the front of the foot where most of the neuropathic ulcers are situated, contact casting (cast w/ pad)
What body parts are involved in peripheral neuropathy?
Peripheral neuropathy causes changes in sensation that begin in the toes and move up to the feet and legs.
What body parts are involved in autonomic neuropathy?
Autonomic neuropathy involves the nerves supplying small blood vessels and sweat glands of the skin, the stomach, the bowels, the bladder, the heart, and the nervous system.
With what is autonomic neuropathy most often associated?
Long-term diabetes, poor control, and elevated blood sugar
What are the symptoms of autonomic neuropathy?
- Abnormal sweating after eating
- Inappropriate response to temperature changes, such as constricting blood vessels in warm temperatures
- Nausea and early fullness when eating, delayed emptying stomach, or vomiting
- Watery diarrhea, often at night and without warning
- Incomplete emptying of bladder, leading to urinary tract infections
- Sexual dysfunction, including impotence and delayed vaginal lubrication
- Drop in blood pressure upon sitting or standing
- Rapid heart beat
- Loss of warning signs of hypoglycemia
What are some treatment options for the above symptoms?
Various medications may be prescribed to control nausea, vomiting, diarrhea, sudden drops in blood pressure, and recurrent urinary tract infections. Penile implants and vacuum systems are useful in treating impotence.
What are the foot-related risk conditions that are associated with an increased risk of amputation?
- Peripheral neuropathy with loss of protective sensation
- Altered biomechanics (in the presence of neuropathy)
- Evidence of increased pressure (erythema, hemorrhage under a callus)
- Bony deformity
- Peripheral vascular disease (decreased or absent pedal pulses)
- A history of ulcers of amputation
- Severe nail pathology
RETINOPATHY
Comprehensive eye examinations are important for diabetics. What is the name of the therapy that can prevent the loss of vision for those with diabetic retinopathy and why is it effective?
Laser photocoagulation therapy/pan-retinal photocoagulation: It causes the abnormal new blood vessels to stop growing and shrink. This type of laser treatment can reduce the risk of severe visual loss by fifty percent.
What surgery is used to treat hemorrhage (into the vitreous chamber)/retinal detachment?
A vitrectomy is performed to remove the blood in the vitreous and also to reattach the retina.
What surgery is used for the treatment of cataracts?
Cataract surgery is an extremely successful operation to remove the cataractous lens and implant a clear lens.
PERIODONTITIS
Why do individuals with diabetes have an increased risk for gum disease (periodontitis)?
High blood glucose helps bacteria grow, making tooth and gum problems worse.
What are the signs/symptoms of gum disease?
- Red, sore, swollen gums
- Bleeding gums
- Gums pulling away from teeth, causing teeth to look long
- Loose or sensitive teeth
- Bad breath
- A bite that feels different
- Dentures that do not fit well
What is the difference between gingivitis and periodontitis?
Gingivitis- gums are infected and pulling away from the teeth; Periodontitis- bone is actually infected and begins pulling away from the teeth, teeth can fall out.
The clinician checks for the amount of tartar (calculus), checks the mobility of all teeth, and evaluates the bite. Why are x-rays needed?
To evaluate the condition of the bone around each tooth and show calculus deposits below the gumline.
Treatment of periodontitis involves “scaling and root planning.” What is this?
Disruption of the infection by thorough cleaning below the gumline by the doctor or hygienist.
What is the goal of treatment?
To remove the tartar and bacteria from the root surfaces to allow healing and reattachment of the gums.
Why are laser treatments sometimes used?
Kills many of the offending bacteria, removes diseased tissue, and encourages gum reattachment to the teeth.
INFECTION
Why are immunizations so important for diabetics?
Diabetics are at high risk for complications, hospitalization, and death from pneumococcal and influenza disease. Vaccines can greatly reduce the risk of serious complications from diseases.
What immunizations are recommended, and what are the indications for repeat vaccination?
Influenza, pneumococcal; repeat with nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as post-organ transplantation.
