RAJIVGANDHIUNIVERSITY OF HEALTH
SCIENCES, KARNATAKA
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Dr. SYAMALA REDDY COLLEGE OF NURSING,#111/1,SGR,MAINROAD, MUNNEKOLALA,MARATHAHALI, BANGALORE – 560037.
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Medical Surgical Nursing.
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6.BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
“Wounds that don’t heal,
Nerves that don’t feel,
No food I can eat at ease,
What a disease I have – DIABETES”. (Rajan)
Diabetes is a major public health problem all over the world. Diabetes mellitus is one of the causes for mortality. Epidemiological studies of diabetes in much population have cast light on the definition and classification of the disease, its early detection, its genetic environmental background, socio economic impact and the effects of the disease on health and quality of life. According to the health statistic of diabetes there were 246 million diabetes clients in the year of 2007 world wide, in India 31.7 million in the year of 2000 and there are 40.2 million in the year of 2008 as estimated. In Karnataka state especially Bangalore there were 12.4 percentages of Diabetes clients. By the year 2030 diabetes mellitus is expected to be 79.4 million in India.
Several epidemiological studies have brought out that the disease is prevalent in the under developed countries because initially it was thought that diabetes is disease of affluent population.The incidence of diabetes mellitus is increasing rapidly in most developed countries due to increasing obesity, inactive life style and an aging population. Estimates by the World Health Organization (WHO) have shown the current global prevalence of diabetes is 3 percentage (194 million people) and is expected to increase in prevalence to 6.3 percent by 2025.It is well established that the care and treatment of diabetes patients consumes large amounts of health care resources. To enable health care payers to budget appropriately, estimating the burden of illness and cost of treatment for diabetes become more important as increasing costs stretch limited health care resources.
Diabetes mellitus is a disease of abnormal glucose metabolism resulting in hyperglycemia due to either a deficiency of insulin secretion or insulin resistance or both. Classic signs and symptoms of diabetes include polyuria, polydipsia, polyphagia, weight loss, headache, tachycardia, palpitation and blurred vision. Diabetes is diagnosed by a fasting glucose of 126mg/dl(7.0mmol/l) or greater or more or a random glucose of 200mg/dl or greater. Impaired fasting glucose is defined as a blood sugar of 100-125mg/dl (5.6-6.9mmol/l).Impaired glucose tolerance (IGT) is defined as an abnormal 2-hour post prandial blood sugar of 144-199mg/dl.
The important aspect of the problem is that over 50 percentage of diabetic population suffers from the disease without knowing about it because of lack of symptom. The chronicity of diabetes and potential for serious complications often results in significant financial burden, decreased quality of life and major life styles changes for patients and their families individual are expected to quickly integrate major life style changes in diet and exercise which are the cornerstone of treatment and most difficult components of self management.
The significance of the epidemiological burden of diabetes lies in the complexity of this metabolic disease which, if left untreated or not appropriately treated, may develop into complications, many of which are life-threatening. Methods of care and treatment of the complications vary depending upon the locality, inevitably resulting in different costs of treatment. Studies collecting the cost of diabetes complications are important to both health economic modelers and health care decision makers to ensure limited resources are distributed efficiently. Indeed, more countries are considering or initiating economic modeling to evaluate current and new treatment therapies.
6.1. NEED FOR THE STUDY
Globally diabetes mellitus affects 10-20 percentages of the elderly in the age group of 65 -74 years and about 40 percent of elderly over the age of 80years. At present, India is considered as the diabetic capital of the world. There are approximately 3.5 crore diabetics in India, and this figure is expected to increase up to 5.2 crore by 2025.Every fifth client visiting a consulting physician is a diabetic and every seventh client visiting a family physician is a diabetic. Keeping in view the alarming increase in the incidence and prevalence of diabetics in India, WHO has declared India as the ‘Diabetic Capital’ of the world.
Diabetics are susceptible to two major acute complications in addition to hypoglycemia that is, diabetic ketoacidosis and hyper osmolar non ketotic coma. Late complications of diabetic like progressive damage to the eyes, kidneys, nerves and arteries represent the major threat to the health and life of diabetics. The maintenance of nearly normal levels of blood glucose concentration will reduce the complications rate and increasingly therapeutic effort is being intensified to save the life of diabetic.
Complications of diabetes are due to pathologic changes that involve large and small blood vessels, cranial and peripheral nerves, the skin, and the lens of the eye. Macro vascular complications are ones that involve damage to the large blood vessel of the brain, heart and extremities. The micro vascular complications of diabetes are retinopathy and nephropathy and are thought to be results of an abnormal thickening of the basement membrane of the capillaries.
Diabetic foot problems may lead to serious complication if not treated properly, e.g. gangrene and amputation.Diabetic foot complications rank among the most common severe complications that most diabetics face. World Health Organizations statistics indicates that 50percent of non-traumatic foot amputations in the world are due to diabetes.So proper management and prevention of foot complications is needed for the client suffer due to diabetes.
The National Cholesterol Education Project (NCEP) considered the presence of diabetes to be equivalent to the presence of coronary heart disease. Sixty five percentages (65%) of all diabetes will die from cardiovascular or cerebrovascular disease. Nearly 45 percentages of all diabetes have peripheral vascular disease.
Elsevier published an article on diabetes control and complications trial. This study was designed to examine the relationship between self-reported diabetic complications and 7 -year mortality in 3050 Mexican American elders aged 65 and older from the Hispanic established population for the epidemiological studies of the elderly(EPESE),conducted in 5 south western states of the united states. Results shows that out of 690 clients with diabetes, 412(59.7percent) subjects had self –reported complications of eye, kidney, circulation problems, amputation, and 276(40 percent) died within the 70 year follow- up compared to patients without any diabetic complications, subjects with only one complications were not statistically significantly different in terms of the 7-year mortality (hazard ratio with 95percent).
For many years now, research has firmly demonstrated the increased mortality in clients with diabetes following myocardial infarction (MI), a prognosis which has persisted despite major advances in acute coronary care. Research has also shown higher than usual mortality rates in clients without known diabetes presenting with hyperglycemia during myocardial infarction. Due to a lack of research evidence, little has been established about how best to manage glycemic control in these clients during the acute phase of myocardial infarction. However, arecent clinical trial has had considerable impact on coronary care practice. It advocates intravenous insulin therapy for all diabetics and clients with hyperglycemia during acute myocardial infarction, followed by subcutaneous insulin for three months, regardless of previous treatment. The evidence for mortality benefit is substantial, but the trial has left some questions unanswered.
Studies have shown that increasing client knowledge regarding disease and its complications has significant benefits with regard to patient compliance to treatment and to decreasing complications associated with the disease. Considering this, we sought to quantify in a population of diabetics visiting our clinic the level of knowledge with respect to different areas pertaining to the prevention and treatment of associated complication.
Adjustment of diet, reduction and avoidance of obesity adequate physical activity, use of oral hypoglycemic agent and administration of insulin if necessary are important in treating the diabetics. Diabetic complication could be prevented by proper education and training of clients, client education and training includeactive participation of the clients which appears to be only efficient solutions for control of the diabetes and its long term complications .It also helps in reduction of hospital bed occupancy. The success in treating diabetics depends on their knowledge regarding causes, risk factors and its complications.
6.2. REVIEW OF LITERATURE
Diabetes mellitus is a multifactorial systemic disease characterized by hyperglycemia and frequently hyperlipidemia. The symptoms are caused by a decrease in the secretion of insulin.Diabetes mellitus is frequently associated with problems of the microvascular and macrovascular systems,neuropathic disorders and dermopathic lesions.By its very nature, diabetes mellitus can be significantly influenced by the treatment components. These treatment components can be delivered only by self-care. No other disease demands so much of the clients own self-knowledge and skills. Thus the professional nurse has the challenge and responsibility to help client gain the knowledge and skill for self management.
The related review of literature has been organized and presented in the following order:
- Definition of diabetes mellitus.
- Incidence and prevalence of diabetes mellitus.
- Etiology of diabetes mellitus.
- Classification of diabetes mellitus.
- Pathophysiology of diabetes mellitus.
- Clinical manifestations of diabetes mellitus.
- Management of diabetes mellitus.
- Studies related to diabetes mellitus.
- Complications of diabetes mellitus.
1.DEFINITION OF DIABETES MELLITUS
Diabetes Mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (Hyperglycemia) resulting from defect in insulin secretion, insulin action or both(American Diabetes Association).
2.INCIDENCE AND PREVALENCE OF DIABETES MELLITUS
Worldwide there are 246 million of diabetic clients in the year 2007.United states (US) 17.7 million,China 20.8 million,Japan 6.8 million in the year 2000.But by the year 2030 US is estimated 30.3 million,China 42.3 million and Japan 13.9 million. In India 31.7 million cases in the year 2000, 40.2 million in 2008 and 79.4 million in the year 2030.Diabetes Mellitus is the fourth leading cause of death.
3.ETIOLOGY/RISK FACTORS OF DIABETES MELLITUS
Family history of diabetes (parents or siblings with diabetes), Obesity, Age, Race/Ethnicity, autoimmune, Eating habits, Absent or insufficient insulin,Viral,Hypertension (> 140/90mmof Hg), HDL Cholesterol level <35mg/dl, History of gestational diabetes and disorder of glucose metabolism.
4.CLASSIFICATION OF DIABETES MELLITUS
The major classifications of diabetes are:
- Type I (Previously referred to as insulin-dependent diabetes mellitus):
It is a metabolic disorder characterized by an absence of insulin production and secretion due to the autoimmune destruction of the beta cells of the islets of langerhans in the Pancreas.Must always be treated with insulin injections.Formerly called insulin – dependent or type I.
ecterized iabetes mellitus
- TypeII(Previously referred to as non insulin-dependent diabetes mellitus):
It is a metabolic disorder characterized by the relative deficiency of insulin production and a decrease in insulin action. Onset is usually insidious, and family history is common.Amenable to treatment with diet,exercise,oral antidiabetic medication,and insulin.Formerly called non-insulin-dependent diabetes or type II.
- Diabetes mellitus associated with other conditions or syndromes.
- Gestational diabetes mellitus (GDM)
It is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy.
5.PATHOPHYSIOLOGY OF DIABETES MELLITUS
Type I Diabetes Mellitus
Due to the etiological factors, there will be destruction of Beta cells in islets of langerhans which causes deficiency of insulin and will leads to decrease anabolism, hyperglycemia, glucosuria, osmotic diuresis, and salt and water depletion. There will also increased secretion of glucacon,cortisol,growth hormones, catecholamine and leads to increased catabolism, increased glycogenolysis,gluconeogenesis and lipolysis,this leads to hyperketonaemia, and diabetic kitoacidosis.If increase or decrease of these leads to death.
Type II DiabetesMellitus
It increased insulin resistance and impaired insulin secretionand decreased glucose uptake by the virus which leads to hyperglycemia.(Smeltzer S.C,Bare.B.G.),(2001).
6.CLINICAL MANIFESTATION OF DIABETES MELLITUS
Polydipsia, Polyphagia, Polyuria, Fatigue, Weakness, Sudden vision changes, Dry skin, Reccurent infection, Sudden weight loss, Nausea, Vomiting, Abdominal pain.
7. MANAGEMENT OF DIABETES MELLITUS
Management of clients with diabetes includes restoring and maintaining blood glucose levels to near normal as possible by balancing diet, exercise, and the use of oral hypoglycemic agents or insulin. Ingeneral, when diabetes is successfully managed, clients avoid the complications of hypoglycemia and hyperglycemia. However, complications may develop in some clients with diabetes despite their vigorous efforts to carefully control the disease.
Initial as well as ongoing client education is vital in helping the client manage this chronic condition. Interventions must be individualized to the clients goals,age,life style,nutritional needs,maturation,activity level,occupation,type of diabetes, and ability to independently perform the skills required by the management plan(Black J.M, Hawks.J.H. 2005).
8. STUDIES RELATED TO DIABETES MELLITUS
Crag et.al. (1998) conducted a study among 4245 clients in Wales, U.K. The study revealed that the length of the hospital stay for clients with diabetes was almost twice that of non –diabetes population. Risk of mortality was confirmed that, among 283 diabetic clients had significant risk factors for peripheral vascular disease, infection, nephropathy, and ulceration.
Catherine, (2001) conducted a study on 415 subjects of type I diabetes and followed up for 4-6.5 years at the University of Wisconsin Madison. Study revealed that frequent hypoglycemia was common in 33 and 35 percentage of participants reported this on 4 and 6.5 years questionnaires, respectively where as severe hypoglycemia occurred much less often. Better glycemic control and more independently related to frequent hypoglycemia. Better control and old age were related to severe hypoglycemic reaction.
Otiniano (2003) conducted a study in South Western States on diabetes and its Complications. In this study, the role of gender on knowledge regarding Diabetes implies that an extremely targeted education programmed is required to empower diabetic women. This study confirms that client’s knowledge about the treatment and complication of diabetes is limited, especially with regard to preventive aspect. There is a definite need to empower patients with the knowledge required to help them obtained maximum benefit from their treatment for diabetes.
Black and Hawks (2005) mentioned that the knowledge of characteristics associated with an increased risk of type II diabetes is very useful in identifying high – risk individuals and those individuals with undiagnosed diabetes. Several studies have provided evidence that there is an association between successfully implemented lifestyle intervention (diet, physical activities, or both) and a decrease in progression to diabetes. The diabetic programmed showed reduction in blood glucose levels among type II diabetic clients can reduce rates of micro vascular and potentially macro vascular complication.
Puri, Meenukalia and Co. (2007) conducted a cross sectional study on profile of diabetes mellitus in elderly in Chandigarh, India. The study was done in field practice area of urban health training centre (UHTC).A total of 273 elderly were registered.74 (27.1 percentage) were males and 31 (41.89 percentage) were females. Results show that out of 28 (26.1 percentage) males and 22 (70.9 percentage) females were in age group of 61-70 years. Maximum number of clients presented with complications of peripheral neuropathy 34 (48.9 percentage), 20 (27 percentage) presented with complication of retinopathy, only 2 (2.7 percentage) with ketoacidosis and hypoglycemia, 9(12.9 percentage) clients were in treatment for diabetic foot.
Diabetes Prevention Programmed Research Group (2002) conducted a unique randomized, placebo controlled trial on reduction in the incidence of type II diabetes with lifestyle intervention or metformin, with a mean follow-up of 2.8years on 3234 participants in United States. Follow up was 93% participants were allocated to an intensive programmed of life style. The intensive lifestyle change consisted of a combined intervention that would maintain a 7% or greater reduction in body weight through, a low calorie and low fat diet, and physical activity Thus the life style intervention reduced the risk of being diagnosed with type II diabetic 50% and Metformin reduces risk by 25%compare to placebo.
9. DIABETIC COMPLICATIONS
Diabetic complication is associated with long term damage to the body and the failure of the various organs and tissues which leads to diabetes complications (Lewis, 2007).
The diabetic complications are mostly divided into two types:-
Acute complications such as hypoglycemia, diabetic ketoacidosis and hyperglycemic hyperosmolar non-ketotic syndrome.
Chronic or long term complications includemicro vascular diseases such as retinopathy, nephropathy, neuropathy, foot and leg problems. The macro vascular diseases such as cardiovascular diseases.
ACUTE COMPLICATIONS
Hypoglycemia
Paulk, L.H.(1983)conducted a description study on the responses to hypoglycemic episodes and self care measures and treatment of hypoglycemia, episodes was gained by the interview of 30 insulin-requiring adult clients with diabetes, aged ranged 19-76 years. Sixty percentage of the sample reported the symptoms of hypoglycemia to be nervousness, weakness and sweating. Sixty two percentage of the severe reaction involving memory 36 percentages of the subjects reported that they did nothing to prevent attacks and used the same substance(juice, candy) to treat the attacks.
Kiln,M.R. conducted a study in 1993, when assessing the risk of hypoglycemia, results showed the incidence of hypoglycemia was 0.3 percentages in non diabetic clients and 0.64 percentages in diabetic client. So it is important to carefully monitor the blood glucose level to both clients and their partners.
Bristol M.S, (2005) conducted a study in clients with Type II diabetes over 15000 clients on controlled hypoglycemia related to Tequin and 0.007 percentage clients in non diabetic, 1.3 percentages in diabetic clients. During this post marketing period, there have been report of serious disturbances of glucose homeostasis in clients with treated with tequin, hypoglycemia episodes in some cases severe, and is associated with hyperosmolar non ketotic hyperglycemia following the initiation of tequin therapy.