Diabetes Revision

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Currently I am extremely busy on placement within the community, and am working alongside a Home-Based Treatment Team (formerly called the Crisis Team). Aside from this, I am also revising for a forthcoming exam which takes place towards the end of September. At the moment I am revising diabetes, and in order to help me clarify my learning, I thought that I would try to rewrite some of the main facts that I have learnt.

The Pancreas and Diabetes

The pancreas is a 90% exocrine and 10% endocrine gland. As an exocrine, it produces secretions which are released into ducts, and also produces digestive enzymes which are passed into the pancreatic duct and then into the duodenum. As an endocrine, the pancreas produces the two hormones glucagon and insulin.

Glucagon is made in the Alpha cells, and promotes the production of glucose through utilising stored glycogen – a process called GLYCOGENOLYSIS. Additionally, glucagon can also make glucose from fats and proteins, and does this through GLUCONEOGENESIS.

Insulin is made in the Beta cells in the Islets of Langerhans, and in conjunction with insulin receptors, it allows cells to uptake glucose in order to obtain essential energy. It does this through making glycogen – GLYCOGENESIS. Insulin also contributes to the maintenance of homeostatic blood glucose levels.

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Other hormones in the body can effect blood glucose levels. The growth hormone (Somatotrophin) can elevate blood glucose levels, as well as Adrenocorticotrophin – producing Cortisol in stressful situations; while the adrenal medulla produces adrenaline and noradrenaline in stressed individuals, once again causing blood glucose levels to rise.

Diabetes occurs in two main types: Type 1 and Type 2. Type 1 is usually an autoimmune disorder which causes the beta cells to stop producing insulin. It typically affects young people, and will need to be treated with insulin injections and dietary monitoring. In Type 2 diabetes the pancreas is still making insulin, but is not working so efficiently. The insulin receptors, which allow the insulin to get into the cells, are much reduced. Type 2 diabetes typically affects middle aged overweight people, and will need to be treated through adopting a healthy diet, some weight loss and exercise.

Symptoms of Type 1 Diabetes –

Hyperglycaemia

These are increased thirst (polydipsia), increased urination (polyuria), glucose in urine (glycosuria), increased appetite (polyphagia) and loss of weight. Within the body, the cells are unable to utilise glucose for energy, and glucose builds up in the bloodstream causing hyperglycaemia. The kidneys filter the blood and try to reabsorb the glucose, but there is just too much for them to cope with. The body’s cells are still trying to obtain glucose, so they break down stored glycogen and turn it into glucose – GLYCOGENESIS, as well as turning fats and proteins into glucose – GLUCONEOGENESIS. As the glucose is unable to be utilised, the blood glucose levels become dangerously high and the person will start to breath rapidly (Kussmaul breathing) in an attempt to get rid of accumulating carbon dioxide. A smell of ketones will be evident in their breath, as these will have been produced by the glucagon making glucose from the fat cells.

 

Hyperglycaemia can be reversed by taking insulin, but where the blood glucose levels are too high, hospitalisation will urgently be needed as Diabetic Keto Acidosis (DKA) will be present. In DKA the blood turns acidic, and if untreated the patient will die by falling into a coma. An individual with DKA will have nausea, vomiting or diarrhoea. In order to counteract the dehydration and acidity, IV fluids will need to be administered, plus a sliding scale of insulin. The body’s electrolytes will also be imbalanced, and potassium will commonly need to be given. In order to regain homeostasis, regular checking of blood glucose levels and electrolytes will be essential.

 

Hypoglycaemia

These symptoms present as sweating, confusion and disorientation, and being pale in appearance. Slurred speech and drowsiness may occur, and the danger is that a hypoglycaemic individual may be perceived as being drunk. Hypoglycaemia will occur as a result of taking too much insulin, or going without food for too long. As long as the individual is conscious, it can easily be rectified by drinking a carton of orange juice, a full sugar cola or consuming some glucose sweets (although liquids are more fast acting). An unconscious patient however, needs to get to hospital urgently, as they can start to get convulsions, go into a coma and brain damage can occur.

Symptoms of Type 2 Diabetes

These can be tiredness, lethargy, blurred vision, repeated fungal infections (thrush), getting up in the night to urinate (nocturia), obesity and hyperglycaemia. People with Type 2 diabetes do not commonly experience hypoglycaemia.

If people with either type of diabetes do not look after themselves, the long term effects can be devastating and include: loss of nerves in the fingers and toes (neuropathy); foot sores and wounds, which may lead to septicaemia and eventual amputation of limbs; damage to the eyes, which may result in diabetic retinopathy, glaucoma, cataracts or eventual blindness; kidney damage; heart disease, and even brain damage.

We only have one body, so clearly we need to look after ourselves, whether we have diabetes or not.  A healthy diet and lifestyle is one of the best ways to do this.

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The wonderful world of the Guide Dogs

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Following on from last week’s blog about diabetes, I recently found out from the Guide Dogs society, that 905,000 in England have diabetic retinopathy.  The condition is a potential complication which can accompany diabetes.  Diabetic retinopathy is damage which is caused to the retina due to high blood glucose levels or high blood pressure.  If hyperglycaemia or hypertension persists long-term, the retina’s blood vessels will gradually deteriorate and begin to bleed or abnormally grow.  Symptoms do not appear until the later stages, and typically present as blurred or double vision, seeing spots or eye pain (NHS Choices).  Blindness may eventually result, and indeed is the main cause of blindness in working age adults (Diabetes UK).  To help prevent diabetic retinopathy, it is essential that people with diabetes look after their health through diet, exercise, good blood glucose control and regular annual eye checks.

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A representative from the Guide Dogs society visited our university and shared some amazing facts about being visually impaired and having a guide dog.  The visitor was accompanied by a beautiful and highly intelligent, fully-trained guide dog called Alfie – a Labrador and Retriever cross.  It has generally been found that these two breeds, along with German Shepherds, usually have the best success with guide dog training. 

guide dog in training

Our visitor told us that a guide dog costs about £50,000 to train and keep, and only 2.5% of people with a visual impairment actually have a guide dog.  There is apparently a waiting list and a system of prioritisation, but also there are some people who consciously choose not to have a guide dog.  This may be because they prefer to use a stick or a person to guide them, or they may not like dogs or have an allergy to their fur.  In view of the last point, Labradoodles have been trained with some degree of success, as poodles are usually beneficial for people who suffer with allergies, as they do not tend to moult hair in the same way as other breeds.  The biggest restriction upon providing more guide dogs however, has got to be funding.  The Guide Dogs society is solely reliant upon charitable funding, and therefore has to raise money through the generosity of others; either through direct donations, fund-raising events or the sponsorship of guide dog puppies.

guide dog on lead

Our visitor told us that 76 people are registered with visual impairment or blindness in England every day.  There is apparently no obligation for a person to include themselves on the register, although opticians will usually notify the Drivers Vehicle Licensing Authority on their behalf, regarding conditions such as glaucoma.  Surprisingly, a person who loses sight in one eye is not classified as being partially sighted, as they usually manage sufficiently with, and adapt to having, just one eye. 

person and dog

As part of the visit I took part in an experiment where I was blindfolded and led by another person.  The blindfold was totally black and I could not see a thing.  My partner led the way, with me holding on to her elbow with a ‘c’ grip.  This is a preferred grip for many blind people, as they can easily let go if necessary, and they have good overall control.  Despite this, I felt really disorientated and afraid to walk at my normal pace.  It was really strange going up a step; having to put both my feet against the edge of the step before going up.  The oddest experience of all however, was going down a sloping ramp, because it made me feel very vulnerable to slipping, as I cautiously felt for the ground with my feet.  My partner and I then swapped over, and I talked her around the same route while she held on to my elbow.  She also found it fairly scary, but seemed to take the step more confidently than I did.  Afterwards we rewarded ourselves with a pat and stroke of the beautiful Alfie.  I could have really cuddled him, but I felt that it was important that I showed some restraint and respect for his role as a guide dog! 

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To find out more about the fantastic work being done, please visit The Guide Dogs, http://www.guidedogs.org.uk/microsites/sponsor-a-puppy?gclid=CPj7o-mcz78CFYIewwod4KEAQA#.U8lDuVJOUth

For more information on sight, visit: Diabetes.co.uk, http://www.diabetes.co.uk/diabetes-complications/retinopathy-symptoms.html

Royal National Institute for the Blind, www.rnib.co.uk

NHS Diabetic Eye Screening Programme, http://diabeticeye.screening.nhs.uk/diabetic-retinopathy

guide dogs 

The Prevention and Management of Diabetes

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This week I have been learning about diabetes – its symptoms, its management and what can go wrong.  The subject choice was particularly apt, given the huge attention that the topic has currently been raising within the media.

On 4th July, Diabetes UK revealed that 738 people are being diagnosed with Type 2 diabetes and 30 more with Type 1 diabetes, every day within the UK.  This is equivalent to a massive 280,000 people every year, and with a further 18 million people having pre-diabetes symptoms already.

So, you may be wondering, what is the difference between Type 1 and Type 2 diabetes?  From what I have learnt, Type 1 diabetes is usually diagnosed in the very young and is basically an autoimmune disease in which the body attacks itself.  In Type 1 diabetes the pancreas stops producing insulin and replacement insulin needs to be injected every single day to keep the person alive.  In addition to this, the person’s blood glucose level needs to be monitored before every meal, and their dietary needs and insulin amounts must be adapted to balance these needs.

Type 2 diabetes is usually diagnosed as a consequence of bad lifestyle choices, and needs to be managed through adopting a healthy diet, taking regular exercise and effectively managing weight.  People with Type 2 diabetes do not need to take insulin, as their bodies are still producing it, but are not able to utilise it effectively.

fruit and veg

One of my nurse lecturers commented that when she started nursing 30 years ago, Type 2 diabetes was only diagnosed in the over 40s age group, and was typical of individuals who were ‘fat, forty and middle-aged’.  Nowadays however, it is increasingly common in people as young as 20.  The reason for this is our Western diet and sedentary lifestyle.  Many of us do not respect our bodies.  We have too much fat and sugar in our diets, not enough fruit and vegetables, too much alcohol, we might sit down in offices all day, we drive our cars everywhere, we sit down in the evening watching TV, we sit down on the Playstation or chat on social media, and added to all that (if that weren’t enough), we might even be indulging in the smoking of cigarettes.  Considering all this therefore, it is not really surprising that the incidence of diabetes is on the increase.

eat well plate

In order to address this spiralling problem, we clearly need to be doing the opposite of all the habits in the paragraph above.  Prevention is undoubtedly the way we need to be going.  To do this therefore, we need to be adopting the principles of the Eat Well plate, as advocated by the NHS.  We require: at least five daily portions of fruit and vegetables; complex carbohydrates such as wholemeal varieties of bread, rice, pasta and cereals; smaller amounts of dairy products such as cheese, yoghurt, eggs and semi-skimmed milk; proteins such as beans, lentils, soya, nuts, fish and lean meat; and very small amounts of fat (preferably unsaturated) such as polyunsaturated margarine and olive oil; plus sparing amounts of sugary treats, such as cake and biscuits.

Added to this, we should be drinking plenty of water, limited amounts of tea and coffee, and non-sugary drinks.  We need at least 30 minutes of exercise daily, which can easily be achieved through a simple walk.  Furthermore, we need to limit our alcohol intake, perhaps just using it as a weekend treat.  We must adhere to our recommended units sensibly, and should avoid resorting to binge drinking.  The perils of smoking meanwhile, are now widely accepted and acknowledged, and it is up to each individual to get the help they need to help them to give up.

If we can all respect our bodies just a little more, our bodies will hopefully continue to work and serve us in the way in which they were intended.  We do not have to give up everything that we love; moderation is the key to good overall health.

So what if you are wondering whether you might be at risk of diabetes already?  What are the signs?  The common indicators are excessive thirst (polydipsia), excessive urinating (polyuria) and perhaps using the toilet throughout the night (nocturia), increased appetite (polyphagia), loss of weight, frequent fungal infections such as thrush, and extreme tiredness and lethargy.  The presence of diabetes can easily be determined through a simple blood test.  A healthy blood glucose level reading should be between 3.5 to 7 mmol/Litre.   If you have any concerns, you should visit your GP.

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At university I am really enjoying learning about the physiology of the pancreas and its role in the production and regulation of insulin levels.  It has also been really fascinating finding out about the pathophysiology – about what happens when things go wrong with the body.  Crucial to my nurse training, is the understanding of how to recognise and deal with low glucose levels (hypoglycaemia) and high glucose levels (hyperglycaemia), and furthermore what either extreme can lead to.

To look after my patients who have diabetes effectively, I have also been learning about the types of health problems that may be encountered, and particularly moreover, when patients fail to properly manage their long term condition.  Diabetes puts people at long term risk of neuropathy (nerve damage to the fingers and toes), nephropathy (kidney damage), retinopathy (damage to the eyes) and heart disease; so it is therefore really important that patients with diabetes attend for regular health check-ups with the diabetes nurse, have their eyes checked at the opticians and have their feet checked with the podiatrist.  With good management and a healthy lifestyle, people with diabetes can enjoy a good standard of living; but without this however, the future could be bleak.

For further information, visit http://www.diabetes.org.uk/