Transcript 2016 NUR 1021 Complications of diabetes

Long-Term Complications of
Diabetes Mellitus
Marion Technical College
NUR 1020
Spring 2016
Chronic complications of diabetes

Categories of longterm diabetic
complications
macrovascular disease
 microvascular disease
 Neuropathy
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
Hypertension -major contributing factor
especially in macrovascular and
microvascular disease
Long-term complications of diabetes mellitus
Chronic hyperglycemia damage to cells &
tissues possibly by:

1. Accumulation of damaging by-products of
glucose metabolism-sorbitol

a. Associated with damage to nerve cells
2. Formation of abnormal glucose
molecules in the basement membrane of
small blood vessels - eye and kidney
 3. Derangement in red blood cell function
leads to ↓in oxygenation to tissues

Macrovascular

Macrovascular complications
Diseases of the large and medium-size
blood vessels
 Occur with greater frequency and earlier
onset in people with diabetes
 Macrovascular diseases


Cerebrovascular, coronary artery, and peripheral
vascular disease.
Macrovascular Changes

Atherosclerotic changes
Blood vessels thicken, sclerose & become
thickened by plaque→adheres to vessel
wall
 Eventual blockage of blood vessel
 Changes occur at an earlier age and more
often in the diabetic

Macroangiopathies

Cerebrovascular Effects

Glucose – stiffens the RBC’s, making platelet
aggregation easier
Leads to TIA’s and causes CVA’s
 People with diabetes- 2x risk of
cerebrovascular disease
 Recovery from stroke impaired if blood
glucose ↑at time of event

Macroangiopathy
Coronary artery disease (CAD)
 MI- 2x as common in men & 3x as
common in women with diabetes
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↑ likelihood of second MI
Ischemic symptoms may be absent
May be secondary to autonomic neuropathy
 Silent MI common in DM

Macroangiopathy
Occlusive Peripheral Arterial Diseases
Occurs 2-3x more frequently in diabetics
 Signs & symptoms

Decreased pulses
 Intermittent claudication (pain in buttock,
thigh or calf when walking)
 Gangrene & amputation – result from
severe form of arterial occlusion

Interventions for occlusive peripheral
arterial disease

Good BS control- medication compliance
 Protect feet from heat and cold
 Foot care:
 Wash daily in warm water, dry well, inspect feet
daily (use mirror to √ bottoms)
 Keep skin soft; gently smooth corns & calluses
 Trim toenails straight- emery board to edges
 Wear closed toe well-fitting shoes & socks – avoid
any irritation of foot
 No smoking (causes vasospasm)
 Check DP and PT pulses; examine feet daily
Reduction of risk factors for
Macroangiopathies

Medical nutrition therapy & exercise
Reduces obesity, HTN & hyperlipidemia
 Obesity increases insulin resistance
 BP control – meds and lifestyle changes


Tight BS control
↓triglyceride concentrations
 ↓ complications


No smoking
Microvascular Complications

Result from thickening of the vessel
membranes in the capillaries and
arterioles from chronic hyperglycemia

Areas most affected
Eyes (retinopathy)
 Kidneys (nephropathy

Microvascular changes

Present in some patients with type 2
diabetes at time of diagnosis

Clinical manifestations usually do not
appear until 10 to 20 years after the
onset of diabetes
Diabetic Retinopathy

Most common cause of new cases of
blindness in people ages 20 to 74 years
Occurs in Type 1 & Type 2 diabetes
 Deterioration of small blood vessels that
nourish the retina


Maintenance of blood glucose to near
normal in type 1 - decrease risk by 74%
Diabetic Retinopathy

Stages:
nonproliferative stage- results in
microaneruysms → capillary fluid leakage→
retinal edema
 proliferative-most severe form- retinal
capillaries become occluded

New fragile capillaries form- hemorrhage easily
and cloud the vitreous→ loss of vision
 Scar tissue also forms→ retinal detachment
 Blurred vision secondary to macular edema
often occurs

Management of Retinopathy

Annual eye exam- screen for retinopathy
 Laser photocoagulation

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Destroys ischemic areas of the retina that produce
growth factors that encourage neovascularization
 This prevents further visual loss - reduces the rate of
progression to blindness
 Done as outpatient- can return to normal ADL
Control BS levels
 Control hypertension
 Cessation of smoking
Other eye problems in diabetes

Glaucoma -results from occlusion of the
outflow channels secondary to
neovascularization
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
This type of glaucoma is difficult to treat
and often results in blindness
Cataracts develop at an earlier age and
progress more rapidly in people with
diabetes
Diabetic Nephropathy

A microvascular complication
Damage to small blood vessels that supply
the glomeruli of the kidney
 Leading cause of end-stage renal disease
(ESRD) in the United States
 Risk of nephropathy is about the same in
patients with either type 1 or type 2 diabetes


Symptoms occur 10-20 yrs after diagnosis of
diabetes
Pathophysiology of nephropathy

Consistent elevation of blood glucose
for a significant period of time
Proteins leak into urine d/t stress on
filtration mechanism
 Pressure in the blood vessels in kidneys
increases
 Stimulates development of nephropathy

Management of Nephropathy

Monitor urine for microalbuminuria, BUN,
creatinine annually
 Blood glucose control to prevent & delay
development of nephropathy
 Use of ace-inhibitor drugs – delay progression
of nephropathy
 Aggressive control of BP- to slow progression
of nephropathy
Other interventions for nephropathy
Decrease protein intake if indicated
(renal diet)
 Low sodium diet
 Avoid nephrotoxic substances
 Dialysis or transplant

Diabetic Neuropathies

Nerve damage d/t metabolic
derangements from diabetes


Demyelination of nerves from
hyperglycemia
Most common types:
sensory or peripheral neuropathy
 autonomic neuropathy

Peripheral Neuropathy
May involve all extremities – usually lower
 Symmetrical and bilateral
 Sx:
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Burning pain (night)
Paresthesia & unable to feel where feet are
Decreased sensation of pain and temp - ↑ risks of
injury to feet
Foot & hand deformities r/t atrophy of small
muscles of the hands and feet
Neuropathy: neurotrophic ulceration
Management -Peripheral Neuropathy
Control of blood glucose -only
treatment for diabetic neuropathy
 Medications:

Analgesics, antidepressants, Neurontin
 Capsaicin- topical cream from chili peppersdepletes the accumulation of pain-mediating
chemicals in the peripheral sensory neurons
 TENS units
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Autonomic Neuropathies
Can affect all body systems
 Three systems often involved

Cardiac
 Gastrointestinal
 Renal

Autonomic - Cardiovascular
Fixed tachycardia
 Orthostatic hypotension


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Change from a lying or sitting position
slowly to avoid fainting & injury
Painless MI
Autonomic GI Tract Neuropathy

Gastroparesis
Delayed stomach emptying and decreased
peristalsis
 Anorexia, bloating, GERD, n & v

Can delay absorption of food and result
in wide swings in blood sugar
 Medication: Reglan ↑motility of GI tract
 Low fat diet
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Autonomic – Urinary Tract Neuropathy
Neurogenic bladder with urinary
retention
 Inner wall of bladder loses ability to
sense pressure
 Bladder empties incompletely


Increases risk of UTI
Treatment of Urinary Tract Neuropathy

Urecholine- cholinergic agonist

Acts on nerves that innervate bladder
Antibiotics for UTI
 Manual pressure q 2 hr – Crede’
 Learn self-catheterization

Reproductive System Neuropathy

50% of males affected- erectile dysfunction
 May have retrograde ejaculation
 Fertility counseling if attempting conception
 ↓ libido & ↑ in vaginal infections in women
 Treatment:
 Meds, surgery
Increased Susceptibility to Infections

Related to high BS levels

Impairs phagocytosis by neutrophils and
monocytes
Loss of sensation (neuropathy) may
delay the detection of an infection
 Treatment of infections must be prompt
and vigorous

Implications with Infection & Diabetes

Healing is slow
Related to impaired vascular supply
 Not enough oxygen to tissue, nutrients,
antibodies d/t poor circulation
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Infections increase the need for insulin
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Often insulin is needed in the hospitalized
diabetic, even if they do not take it at home
Nursing Role

Assess for complications in the diabetic
patient r/t the cardiac, vascular and
nervous systems
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Educate the patient and caregiver about
prevention and management r/t chronic
complications of diabetes