Type I:

- Family hx

- Race

- Childhood viruses

Type II:

- Age

- Race/ethnicity (AA/Native American/Hispanic > Caucasian)

- Family hx

- Gestational diabetes

- Low birth weight

- Increased BMI

- Central obesity ('apple' shape)

- Sedentary lifestyle

- High fat and refined carb diet

- Hypercholesterolemia

- Smoking

- Htn

- Stress

- Low socioeconomic status

- Heart disease 3-4x more common

- Stroke 2-4x more common

- HTN seen in 75% of patients

- Leading cause fo retinopathy

- Leading cause fo kidney failure

- Diabetic neuropathy in 30%

- PAD causes > 60% of LE amputations

- Normal blood glucose:  80-110 mg/dl

- Symptoms of hyperglycemia and blood and urine glucose and ketone abnormalities AND

- Plasma glucose level ≥ 200 mg/dl (without regard for time of last meal)

- Fasting plasma glucose level > 126 mg/dl

- 2-hour postload glucose > 200 mg/dl during OGTT

- Fatigue/weakness

- Weight loss (Type I) with increased intake

- Polyphagia:  Increased hunger

- Polydipsia:  Incrased thirst

- Polyuria:  Increased urination

- Hyperglycemia

- Glycosuria:  Increased sugar in the urine

- Ketosis (Type I)

- Blurred vision

- Autoimmune pathology of Islets of Langerhands-no insulin production

- May also be peripheral insulin resistance

- Genetic predisposition

- Exogenous insulin required

- Risk factor-First degree relative with type I DM

- Normal or even elevated insulin levels

- Insulin resistance to cellular attachment and action

- Insulin secretion may be impaired

- 80% obese; 20% lean but with fat distribution in abdominal area

- Reduced sensitivity to action of insulin

- Excessive hepatic glucose production

- Impairment in insulin production

- Family hx

- Obesity

- Ethnicity:  Black, Hispanic, Native American

- Age > 45

- Hx of gestational diabetes

- Giving birth to baby > 9 lbs

- Hx of impaired fasting glucose or glucose intolerance

- Htn > 140/90 mm Hg

- HDL < 35 mg/dl and/or TG > 250 mg/dl

- PVD (PAD)

- Cardiovascular disease (CAD)

- Cerebrovascular disease (CVA)

- Skin and nail changes

- Impaired wound healing/infection

- Nephropathy secondary to atherosclerosis

- Retinopathy

- Nephropathy

- Neuropathy

- Highest in Type I

- Non-proliferative:  Microaneurysms, exudates, retinal hemorrhage

- Proliferative:  Neovascularization, vitreous hemorrhage with retinal detachment

- Macular edema

- Cataracts/glaucoma

- Manage blood glucose levels

- Thickening of glomeruli, tubules and Bowman's Capsule impairs filtration

- Atherosclerosis of renal vessels

- Chronic pyelonephritis (infection)

- Hypertension

- Polyuria

- manage with tight glucose control

- 50% of patients with DM

- Microvascular:  Micro-infarcts of small vessels → hypoxia of nerves and nutritional deficit = mononeuropathies or mononeuropathy multiplex

- Metabolic disturbances and fluid and electrolyte imbalance = bilateral, symmetrical polyneuropathies (stocking/glove neuropathy)

- Pain, hyperesthesia, dysesthesia, paresthesia

- Loss of protective sensation, light touch, pinprick, thermal, vibratory and position sense

- Weakness, atrophy, decreased DTR's

- Most are mixed:  Sensory and motor

- Degeneration fo denervated joints secondary to repeated trauma from proprioceptive loss

- Subluxation → faulty biomechanics and tissue breakdown

- Motor and sensory loss will also affect biomechanics and ultimate joint and tissue deformity

- AKA neuropathic arthropathy

- Occurs when a joint deteriorates due to nerve damage

- Joints are deprived of pain and position sense due to the neuropathy:

• Small fractures
• Lack of blood flow
• Potential for infection
• More susceptible to injury
• Joint nourishment is reduced
• Severe damage, usually in the joints of the foot
• Poor gait and increased incidence of ulcer and calluses

- Affects nerves that control the heart and other organs

- Parasympathetic system may be involved before sympathetic system

- Resting tachycardia

- Exercise intolerance

- Orthostatic hypotension

- Impaired sweating adn temperature regulation

- Hypoglycemia unawareness

- Delayed gastric emptying

- Diarrhea/constipation

- Atonic bladder

- Increasing myocardial oxygen demand secondary to higher resting HR

- Decreasing myocardial oxygen blood flow by increasing coronary vascular tone at sites of coronary stenosis

- Decreasing coronary perfusion pressure during orthostatic hypotension

- Eliminating early warning signs (anginal perceptions)

- Biomechanical imbalances

- Adhesive capsulitis

- Carpal tunnel syndrome

- Hand stiffness:  Dupuytren's contracture, flexor tenosynovitis, trigger finger

- Increased risk of injury:  Impaired sensation, poor circulation, repeated trauma, faulty biomechanics

- Ulcerations:  Dry, inelastic skin

- Increased skin breakdown

- Fat atrophy

- Glycosylated collagen and keratin-skin immobile

- Impaired healing

- Hypoglycemia:  BG < 70

- Hyperglycemia:  BG > 300

- Ketoacidosis

- Usually sudden onset

- Sympathetic s/s:  Fatigue, weakness, malaise, irritability, hunger, pallor, perspiration, piloerection, increased HR, palpitations

- CNS:  Mental disturbances, HA, incoordination, blurred vision, slurred speech, convulsions, coma

- Overdose of insulin

- Irregular use of medications

- Steroids, birth control pills, alcohol, or other drugs that can affect BG levels

- Delayed or inadequate mal

- Skipped meal

- Exercise or overexertion

- Stress

- Provide carbohydrate source:  Fruit, juice, honey, glucose tablets or gel

- Perform BG test

- Unconscious person requires medical attention

- Determine cause(s) and address these

- Gradual onset

- Thirst = polydipsia

- Polyuria leading to decreased urine output and volume loss

- Severe dehydration

- Decreased temperature

- Abdominal pain and distension

- Confusion

- Lethargy

- Altered mental state

- Tachypnea (rapid breathing)

- Seizures/coma

- Can progress to hyperglycemic, hyperosmolar, nonketotic coma (HHNK)

- Extremely high BG (400-500 mg/dl)

- Hyperosmolar = increased BG pulls water out of brain and other tissue leading to severe hydration

- Decreased consciousness

- Death rate up to 40%

- Missed insulin or other medication dose

- Taking too much insulin

- Trauma, surgery, stress, pregnancy, puberty, infection, development of insulin resistance

- Short-acting insulin

- Electrolyte and fluid replacement gradually so as not to induce CHF, intracerebral swelling or renal overload

- Gradual onset

- HA

- Thirst

- Dry mouth

- Hot, dry skin

- Muscle cramps or weakness

- Flushed face

- Elevated temperature

- Hyperventilation

- Serum pH < 7.3

- Fruity odor on breath or in urine

- Abdominal pain and distension

- Polyuria

- Dehydration

- Lethargy/confusion/coma

- Inadequate insulin

- Infection

- Trauma

- Medications:  Beta-blockers, CA channel blockers, steroids, thiazides

- Alcohol abuse

- Hypokalemia

- Myocardial ischemia

- Surgery

- Pregnancy

- Renal failure

- Stroke

- Insulin support

- Careful rehydration

- Restore electrolyte balance

- Determine and correct causes