Grija Pretul pacientii cu diabet zaharat – teoretice data

Definition Diabetes mellitus is a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia disorder of carbohydrate metabolism, lipid and protein, due to relative or absolute deficiency of insulin secretion efficiency of insulin action or both. (WHO, 1998). Chronic hyperglycemia is associated with

chronic complications in many organs (eye, kidney, blood vessels, nerves, heart). (American Diabetes Association 2004)
Classification
Type 1 diabetes (pancreatic beta cell destruction leading to absolute insulin deficiency)
A. autoimmune
B. idiopathic
Type 2 diabetes (ranging from predominantly insulin resistance associated with relative deficiency of insulin secretion, until the deficiency of insulin secretion predominantly associated islands | inorezistentei)
Other specific
– Diabetes associated with other conditions or syndromes
• genetic defects of pancreatic beta cell
• genetic defects of insulin action
• diseases of the exocrine pancreas
• endocrine
– Diabetes induced by drugs or chemicals
• Infections
– Rare forms produced by immunologically mediated mechanisms
– Impaired glucose tolerance (IGT);
– Gestational diabetes (DZG);
Diagnosis
1. clinical presumption
– Classical clinical picture: polyuria, polydipsia, polyphagia, weight loss
– Nonspecific symptoms: fatigue, dizziness, pruritus
– Ketoacidosis inaugural
– Highlighting specific chronic complications of diabetes during checks in different
medical services (cardiology, ophthalmology, neurology, dermatology, surgery)
2. Biochemical confirmation – diabetes is often asymptomatic and the diagnosis is due to the presence of elevated blood glucose values. Active detection of the disease is through the systematic identification of glucose, and in doubtful cases by performing oral glucose tolerance test (OGTT).
> Fasting plasma glucose (repeated)> 140 mg% (> 7.8 mmol / 1);
> TTOG 2 hours postprandial glucose> 200 mg% (> 11.1 mmol / 1).
3. diagnostic criteria:
• presence of signs and symptoms for diabetes and glucose evocative accidental (performed at any time of day)> 200 mg% (11.1 mmol / 1)
• fasting glucose (at 8 hours after the last meal)> 126 mg% (7 mmol / 1)
• a 2-hour glucose levels determined during the OGTT> 200 mg% (11.1 mmol / 1).
For the diagnosis of diabetes using blood glucose determination in venous and capillary blood not made using glucometers. Confirmation of diagnosis of diabetes is made only if the two values ​​are pathological glucose. Determination of glucose is made from serum, plasma (2 ml of blood are needed) or capillary blood. If dosing using serum sample should be processed within one hour after collection. For the determination of plasma following substances can be used as an anticoagulant: sodium fluoride, EDTA, heparin (Na F is recommended for preventing glycolysis process). In determining glucose using colorimetric methods (eg, based on the reaction between glucose and ortotoluidina) and methods using the glucose oxidase enzyme. Fasting glucose:
– Normal: 60-100 mg%
– Impaired fasting glucose: 100-125 mg%
– Diabetes> 126mg%
Patients with impaired fasting glucose (fasting glucose impared – IFG) are at increased risk of progression to diabetes and cardiovascular disease.

Oral glucose tolerance test – Patient Preparation:
– 3 days prior to OGTT ensure normal food intake (at least 150 grams. Carbohydrate / day)
– Fasting for 10 hours
– Refrain from smoking before and during the test
Technique: payments morning (7:30-10 am)
– The patient sits in sitting position
– Venous blood is collected
– Is given 75 grams glucose powder dissolved in 200-300 ml water. to be consumed in less than 3 minutes. In the event of nausea patient can consume lemon juice.
– Resting on a chair 2:00
– Harvesting blood glucose 2 hours after glucose ingestion
Harvesting is done anticoagulant venous blood represented oxalate or heparin sodium.
interpretation:
Glucose at 2 hours:
• Normal – <140mg%
• impaired glucose tolerance: 140-199 mg%
• Diabetes:> 200mg%

Diagnosis of diabetes type
diagnosis of complications
January. acute complications.
• Surgical:
– nonspecific
– Specific: gangrana diabetic vitreeana hemorrhage, cataract
• Medical:
– Organic: myocardial infarction, stroke, cerebral, pulmonary tuberculosis
– Metabolism:

– Diabetic ketoacidosis
– Hyperosmolar coma, lactic acidosis
– Hypoglycemic coma
• infectious
– Bacterial infections – specific and nonspecific
– Fungal Infections
– Infection outbreak / organ
– Systemic infections

2. chronic complications
– Microangiopathic (DZ specific complication characterized by touching small vessels)
 diabetic retinopathy (damage to the retinal microcirculation)
 diabetic nephropathy (glomerular disease predominantly inflammatory nature developed in the diabetic)
– Neuropathic (nerve damage due to diabetes metabolic disorders specific):
 Peripheral sensory-motor polyneuropathy
 autonomic neuropathy
– Macroangiopathic
 lesions in the large vessels: arteries of lower limb arteries
coronary, cerebral arteries
 heart, brain

Treatment of diabetes
1. Diet: normocalorica (calorie to overweight), balanced in nutrients, (hipolipidica to overweight), no concentrated sugars
2. Changes in lifestyle (exercise, weight loss, smoking cessation, limiting ethanol consumption)
3. Treatment oral / insulin / combined
4. Treatment of risk factors
5. Management of complications
Plan care of patients with diabetes

1) Evaluation of the patient with diabetes
• Clinical evaluation of signs and symptoms
This acetonaemia a whale (smell rotten apples) in patients with diabetes
decompensated
a skin exam:
■ Dry skin with persistent skin fold in diabetic ketoacidosis
■ clammy skin, sweating, pale in patients with hypoglycemia
■ clammy skin in the upper half of the body and dry in the lower – mark diabetic neuropathy
■ lesions by scratching the side legs anhidrosis
■ cheekbone hyperemia in patients with DM unbalanced
an examination appendages – injuries nail fungus, panaritii
an examination of body fat:
■ weighing to calculate BMI and waist measurement to assess the nutritional status and cardiovascular risk
■ This area of ​​lipodystrophy (swelling secondary tegument insulin injection in the same area) Do not administer insulin in these areas because it absorbs
an examination of hands:
Thickening of the skin with their feeling-cheiropatie cartonificare
– Assessment and Coordination manualitatii patients on insulin therapy
– Assessment of visual acuity in patients on insulin therapy
a foot exam:
– Deformation induces collapse biomechanics of plantar vault likelihood of ulceration
– Clavus (indicating the presence of mechanical stress, risk of ulceraiii)
– Plantar Hyperkeratosis cracks – the gateway to infection
– Hematoma subunghiale (dark purplish red area)
– Ulceration
– Gangrene
– Presence / absence of pulse in art. Pedi
– Amputations
– Edem

Paresthesia
– Impaired tactile and painful sensitivity
A change in appetite (polyphagia secondary metabolic imbalance, abnormal eating behavior)
a nausea, vomiting, abnormal transit, diarrhea, constipation, changes in urination. TDS – autonomic neuropathy
blood pressure measurement in supine and standing positions (2 minutes upon standing)
Evaluation of metabolic control (DZ balanced, unbalanced, uncompensated)
 Determination of fasting glucose and postprandial (2 hours after a meal) by collecting venous blood or capillary blood using glucometers
 Determination of capillary blood glucose
■ Materials: meter (AccuChec, GlucoVal, Medisense), without wool alcohol, type needle or lancet puncture devices)
■ Principle: determination of glucose by enzymatic methods (glucose oxidase)
■ Technique: fingertip puncture. The first drop was removed with cotton dry, clean, and the second drop is applied to the test strip device
 performing glycemic profile – determination of glucose at certain times (6, 10:30, 12, 15:30,18, 21:30 3)
 Determination of HbA1c – glycated hemoglobin (hemoglobin fraction which undergoes glucose binding his chains). Dosage HbA1C is fully harvested venous blood anticoagulant, where the samples can not be processed on the day of harvest can be stored for one week at a temperature of 2-8 ° C. Normal HbA1c-value 4-6%.
 Determination of cholesterol and triglycerides in the morning is nemincate as triglyceride concentration increases to an hour after eating, reaching the maximum at 4 hours and returning to baseline levels within 12 hours. Determined value is higher when the blood is collected in standing position than in supine. Harvesting with stasis leads to an increase of 20% cholesterol. The use of heparin as an anticoagulant which influences the outcome (citrate and oxalate increased plasma lipid concentrations and EDTA decrease the 3% value). Serum or plasma can be stored at temperatul. 4 ° C for one week free to modify lipid concentration.
 Determination of urinary glucose is semiquantitatively using Dipstick urine test strips spontaneous emission type or quantity of urine harvested 24 hours.
 ketonuria is semi-quantitative determination of urine emitted spontaneously by type Dipstick tests.
 Determination of alkaline reserve and ionogramei of venous blood collected on heparin
 weighing and measuring patient
Evaluation of acute and chronic complications
• acute complications
• Explorations used to assess chronic complications
• Diabetic retinopathy:
– Fundus examination
– Slit lamp eye funduiui
– Fluorescein angiography
– Ocular Ultrasound
A diabetic nephropathy:
– Microalbuminuria – is determined semiquantitatively in | urine passed urine spontaneously and quantitatively harvested 24 hours (keeping in conditions to avoid microbial proliferation is important not to disturb the result of the determination)
– Proteinuria
– The albumin / creatinine urinary
– Urinalysis examination
– Urea, creatinine
– Calculation of creatinine clearance
A Diabetic Neuropathy
– Testing pain sensitivity
– Monofilament testing tactile sensitivity
– Testing of the tuning fork vibratory

– Testing pain sensitivity
– Nerve conduction velocity
Diabetic macroangiopathy
– Cholesterol, triglycerides, HDLC, LDLC
– Oscillometric
– ECG
– Lower limb arteries Doppler
– Carotid artery Doppler
– Angiography
Assessment of the patient’s psychosocial profile
• Knowledge of patient attitudes towards the illness, healthcare, and to expectations about the treatment of the disease is useful to appreciate how he wants to participate in self-care
• Assessment of socio-economic and educational level, knowledge of family customs, religious beliefs is useful in identifying barriers that may arise in the way of treatment, and to analyze how the patient can participate in their own care.
• Assessment of family support
• Conduct psychological examination for the diagnosis of depression, eating disorders and has a cognitive impairment.
2) Therapeutic Targets
• Elimination of symptoms
• Obtaining optimal metabolic control through dietary and pharmacological means, maintaining clinical and biochemical parameters in order to prevent acute and chronic complications:
• Early diagnosis of diabetes.
• treatment of cardiovascular risk factors: obesity, hypertension, dyslipidemia, smoking cessation, and comorbidities
• Reduce anxiety;
• Dialogue with the patient (explaining appropriate and adapted to cause disease, present status, possible complications, the importance of dietary and pharmacological therapy);
• Obtain patient and his family adherence to therapeutic program.

Biochemical targets of metabolic control in patients with diabetes

Degree of control
Parameter good Precarious limit
Biochemical

80-110mg% glucose 110-140 mg%> 140mg%
Fasting

2-hour glucose 100-145 mg% 145 – 180mg%> 180mg%
HbA1c <6.5% 6.5 -7.5%> 7.5%
HbA1 <8% 8 -9.5%> 9.5%
Cholesterol <200mg-250mg% 200%> 250 mg%
Triglycerides <150 mg% 150 – 200mg%> 200 mg%

Evaluation of anthropometric parameters by BMI
Men <25 kg/m2 kg/m2 25-27> 27 kg/m2
Women <24 kg/m2 24-26 kg/m2> 26 kg/m2
3) Therapeutic Means
• Education of patient care in terms of
– Diet
– Physical activity
– Insulin and oral hypoglycemics
– Self-
• Reducing Anxiety

Educaţia

Cel mai frecvent rolul de educator revine asistentei medicale. Educaţia pacientului cu DZ este individualizata si continua si nu poate fi disociata de noţiunea de tratament.

Principii:

–         educaţia se face de catre personal medical instruit in acest sens

–         trebuie sa fie adaptata fiecărui pacient ca limbaj si conţinut

–         noţiunile prezentate sa fie in concordanta cu situaţia clinica virsta, nivel socioeconómic gradul de educaţie

–         numărul noţiunilor noi prezentate sa nu depasasca 4-5

–         durata şedinţei de educaţie sa nu fie prea mare

Obiective:.

–         imbunatatirea stilului de viata

–         obţinerea compliantei la tratamentul farmacologic:

ü  respectarea programului individual de supraveghere medicala si a vizitelor medicale periodice

ü   semnalarea rapida a oricărei modificări semnificative a stării clinice

ü   sesizarea si semnalarea rapida a factorilor precipitante agravanţi ai dezechilibrului metabolic

ü  motivarea pacientului in ceea ce priveşte prezentarea la medic pt urmărirea TA, microalbuminuriei, examenul fundului de ochi, alterarea sensibilităţii periferice

–         instruirea bolnavului si a anturajului  pentru  auto/monitorizare  si  auto/ingrijire prin cunoaşterea unor noţiuni despre:

o  obiectivele tratamentului

o  metode de tratament

o  complicaţii acute si cronice

       o  educaţia privind necesitatea intreruprii fumatului, controlul greutăţii si al TA

o  cunoaşterea necesitaţii profilaxiei complicaţiilor comice

o  cunoaşterea factorilor de risc cardiovasculari

o  piciorul diabetic

o  automonitorizarea

o  conduita in situaţii speciale

o  sarcina si contraceptia

Dietă   Obiective:

–         controlul glicemiei

–         controlul greutăţii ponderale

–         controlul profilului lipidic

–         asigurarea aportului caloric adecvat menţinerii stării de sănătate, a creşterii si dezvoltării

–         prevenirea complicaţiilor

–     imbunatatirea calităţii vieţii

Etapele elaborării dietei:

Explicarea şi însuşirea principiilor dietetice ale alimentaţiei diabeticului

–          Calculul individualizat al necesarului caloric/dietei funcţie de virsta, sex, activitatea fizica, starea de nutriţie, stare fiziologica, patologia asociata

ü   Estimarea necesarului zilnic diferenţiat al principiilor alimentare în realizarea raţiei alimentare, cu  repartiţia caloriilor pe principii nutritive ( glucide, lipide, proteine):

□       Glucide = 40-50%;

□       Lipide = 30-40%;

□ Proteine = 20-30% – 0,80gr/Kgcorp/zi

– fibre alimentare – 40gr/zi

– restrictie sodica – 1 gr/1000calorii

–         precizarea cantităţii de calorii pe 24 ore

–         noţiuni despre edulcorante şi meniuri şi tehnici speciale ale bucătăriei diabeticului a alimentelor permise la discreţie, permise cântărite şi interzise diabeticului

–         alegerea alimentelor pe 24 ore

–         repartiţia alimentelor pe mese

–         precizarea regulilor de pregătire a alimentelor

! Determining the diet, calculate caloric needs and the nutrieriti distribution is made by a physician.

In diabetic diets carbohydrates and ranks first according to the amount they contain are divided into
– Foods that contain carbohydrates
– Foods containing carbohydrates and should be weighed
– Foods containing carbohydrates> 50% and are forbidden
Establishing food to be consumed takes into account the carbohydrate content:
 forbidden foods: sugar, honey, candy zahar.biscuiti, halvaua, fruit juices, fruit
dried grapes, wine, alcohol, sweet cream, bacon
 allowed foods: meat, fish, sausages, canned meat and fish, viscera, cheese, cottage cheese, eggs, cooking oil and raw green vegetables (cucumbers, tomatoes, cauliflower, cabbage, green beans, lettuce, spinach, zucchini, nettles, radishes,
mushrooms, peppers, leeks, eggplant)
 foods that weigh: bread, pasta, milk, cottage cheese, dairy products, pulses (beans, peas, rice), potatoes, vegetables (carrot, celery, parsley, beets, onions), fruit (apples, strawberries, raspberries, apricots, peaches, oranges, grapefruit, watermelon, melon, quince, cherry May cherry)
Education on diet is to:
– Knowledge of food restrictions and need their
– Knowing the amount of carbohydrates that should be consumed in 24 hours
– Knowledge of the food division tables
– Knowledge of equivalent carbohydrate carbohydrate content of food knowledge knowledge of the relationship between carbohydrate intake and blood glucose smoking cessation, limiting salt intake and alcohol consumption
– Rules for preparing food diet
– The use of sweeteners
Physical activity is indicated due to favorable effects on metabolic control, cardiovascular beneficial effects, allowing weight loss, lowering medication. Prescription: physical activity is done in terms of age, duration of disease, cardiovascular status, presence and type of chronic complications, degree of training, patient availability. Do not practice when ketones in the urine or if your blood sugar is in function of 250mg/dl
Patients with diabetes without complications balanced allowed to practice any form of physical activity, except those at risk (diving, mountain climbing).
Education on physical activity:
– Encourage the patient to practice exercise (eg walking 30 minutes / day)
– Education on avoiding hipogiicemiei
– Testing blood glucose before and after exercise
– Knowledge of the beneficial effects
Reducing patient anxiety and his family
– Education and approved alificata
– Avoid stress
Achieving compliance to the patient and caregivers toward the individual patient’s treatment plan
– Respect for the individual program of medical surveillance and regular visits scheduled;
– Report any significant changes in rapid clinical condition;
– Rapid alert notifications and precipitating factors / worsening of diabetic patient’s metabolic imbalance

Patient education regarding insulin therapy technique
Preparation of materials required:
l) knowledge of the type of insulin recommended in pharmacokinetics (the start of the hypoglycaemic action, top action, duration of action); adaptation to insulin Plan
Type of insulin debut full length action action Action
Rapid-acting insulin analogues (Apidra, Humalog, NovoRapid <0.25 0.5 – 1.5 3-4
Short-acting insulin Actrapid, Humulin R, Insuman fast 0.5 to 1 2-3 3-6
Intermediate-acting insulin, Humulin N, Insulatard, Insuman Basal 2-4 6-10 10-16
Long-acting insulin – long-acting analogues (Lantus, Levemir) 2-24

Premixed Insulins
-Mixed 20/80, 30/70, 40/60, the short-acting insulin and NPH (Humulin M3 Mixtard 30HM, Insuman Comb 25, Insuman Comb 50
– Mixtures of rapid-acting analogues and NPH (Humalog Mix 25, Humalog Mix 50, NovoMix 30
0.5 to 1

<0.25
2-3/6-10

0,5-1,5 / 6-10
10 to 16

2) knowledge management device:
– The syringe (syringes are used only 100 U / ml). Those varying sizes of 12 mm, 8 mm,
6 mm and can be reused by the same patient to produce stinging or discomfort for at least 7 days.

The technique of injection (subcutaneous)
a choice of injection site
an intermediate resuspension mixing insulins
air into a vial (read units to be taken)
a the dose of insulin by vacuuming it slowly so as not to form bubbles
a not antiseptizeaza injection
subcutaneous injection
removing a needle without compressing region then
– Pens, pen-shaped device that is inserted in special vials of insulin (cartridges), easy to handle and can be used by those with impaired vision
– NovoLet, OptiSet – filled delivery devices
2) the knowledge of injection – subcutaneous injection (arm, thigh, abdomen, buttock);
 injection site rotation to prevent lipodystrophy;
 Alternate management region to prevent variations in absorption and overall risk of late;
 Avoiding insulin administration regions to be requested immediately by intense exercise (increased absorption of insulin, I risk of hypoglycaemia);
3) Storage:
– Avoid extreme temperatures and direct exposure to sunlight
– Keep at room temperature – 14 to 30 days
– Open bottle stored at 2-8 ° C within 1-2 months
– Dark bottle stored at 2-8 ° C until expiry
4) knowledge of routes of administration:
– Subcutaneous
– Intramuscular – faster absorption of insulin
– Intravenous – administration only short-acting insulins
– Insulin pump – uses the analogy made fast and continuous subcutaneous insulin injection
5) Knowledge of insulin doses
6) knowledge of adverse effects of insulin therapy:
– Hypoglycaemia – insulin injection sites to be requested immediately by exercise;
deviations from the diet
– Lipodystrophy
– Practical allergy to insulin. eliminated by using human insulin
– Edema
– Blurred vision
– Weight gain
– Pain by injection of needle used, scrap alcohol on the skin, intradermal injection,
– Use of insulin in the refrigerator cold
After the injection:
1.Prevenirea any hypoglycemia (sugar candy);
2. In case of doubt regarding hypo-or hyperglycemia is preferable to treat the case as hypoglycemia;
3. If hypoglycemic patients who can not swallow should be administered sc glucagon, insulin syringe;

Always wear 4.Pacientul carry a medical documents identifying him as a diabetic and mention the type and dosage of insulin needed.
Self-monitoring allows a flexible lifestyle and is indicated in patients treated with oral agents (not reaching therapeutic goals) and those treated with insulin. Is performed using glucometers. All patients with diabetes should be encouraged to automonitorizeze, especially those treated with insulin, the sulfonylureas and the risk of hypoglycaemia unconscious.
The purpose of the self is a change regimen by patients according to blood glucose levels, diet, physical activity, presence of intercurrent disease. The accuracy of measurements depends on the device and what you use and why patients should be monitored by recording the data, check the memory meter, comparing data recorded with the laboratory determination of HbAlc, calibration check. Determined from capillary blood glucose value is 10 -15% higher than that determined from venous blood. In terms of frequency of testing this point in depending on individual therapeutic goals, the degree of motivation of the patient, socioeconomic level, age, level of education. For patients with type I diabetes indicate a minimum of 3 tests per day. If the value determined blood glucose greater than 250 mg% patients should be educated to test ketones in the urine.

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