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components that originates from glucose intolerance that in turn

leads to hyperglycemic states (increased plasma glucose levels).

Hyperglycemia can result from insufficient insulin production, ineffective receptive cells for insulin, or both. Insulin promotes storage of glucose as glycogen in muscle tissue and the liver. Deficiency of insulin

leads to increased levels of plasma glucose.I.6,29

The diagnosis of diabetes is based on the presence of any one of the

following three factors6.30:

I . Presence of polyuria, polydipsia, weight loss, blurred vision, and

random plasma glucose (regardless of last meal) greater than or equal

to 200 mgldl

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AClITE. CARE HANDBOOK FOR PHYSICAL THERAPISTS

2. Fasting plasma glucose greater than or equal to 126 mg/dl (no

caloric intake for at least 8 hours)

3. Two-hour-postload glucose greater than or equal to 200 mgt

dl, using a 75-g oral glucose load dissolved in water

The diagnosis is confirmed when one of the above factors is also

found on a subsequent day.6,3o

The two primary types of diabetes mellitus are type I (insulindependent or juvenile-onset diabetes) and type 2 (non-insulin-dependent Ot adult-onset diabetes). After much debate on the classification of diabetes, the current terminology for diabetes uses type 1 and type

2 diabetes to distinguish between the two primary types.30,JI Orher

forms of glucose intolerance disorders exi t but arc nOt discussed in

this text.

Type 1 Diabetes

Type 1 diabetes is an autoimmune disorder with a genetic-environmental etiology that leads to the selective destruction of beta cells in the pancreas. This destruction results in decreased or absent insulin

secretion. Type 1 diaberes represents 5-10% of the population with

diabetes and generally occurs in individuals under the age of 40

years.29-33 Other etiologies for type I diabetes exist bur arc nOt discussed in this text.

Classic signs and symptoms of type I diabetes are described in the

previous section with the diagnostic criteria for diaberes.6•29

Management of type 1 diabetes may consist of any of the

following.l2-R

o

Close self- or medical monitoring of blood glucose levels (Table

11-8).

•

Insulin administration through oral medications, intramuscular

injection, or continuous subcutaneous insulin infusion (CSII)

pump. CSII therapy has been shown to be as effective as multiple

daily injections of insulin, while also providing the ability to mimic

a more natural glycemic response in fasting and postprandial states

(Table 11-9).

•

Diet modification based on caloric content, proportion of basic

nutrients and optimal sources, and distribution of nutrients in

daily meals.

o

Meal planning.

•

Exercise on a regular basis.

ENDOCRINE SYSTEM

675

Table 11-8. Tests to Monitor Control of Diabetes

Test

Description

Self-monitoring

Blood glucose fin

Monitors immediate control of diabetes. Very effecger stick samples

tive in establishing the correct insulin dosages and

preventing complications from diabetes.

Reference, 60-110

Capillary blood is obtained by a needle stick of a finmgldl

ger or an earlobe and placed on a reagent strip.

The reagent strip is compared to a color charr or

placed in a porrable electronic meter to read the

glucose level.

Patients in the hospital can also have blood drawn

from an indwelling arterial line, for ease of use,

without compromising accuracy of measurement.

Urine testing

A reagenr strip is dipped in the patienr's urine, and

the strip is compared to a color chart to measure

glucose levels in the urine.

Provides satisfactory results only for patients who

have stable diaberesj otherwise, results can be

insensitive for truly delineating hyperglycemia.

Medical monitoring

Glycosyl.ted

Hyperglycemia results in saturation of hemoglobin

hemoglobin

molecules during the lifespan of a red blood cell

(GHB)

(approximately 120 days).

Reference, 7.5-

Measuring the amount of GHB in the blood provides

11.4% of toral

a weigh red average of the glucose level over a

hemoglobin for

period of time and is a good indicator of long-term

a patient with

control of diabetes, without confounding facrors

controlled

such as a recem meal or insulin injection.

diabetes

Measurements are performed every 3-6 mos.

Fructosamine or

Similar ro GHB test, hyperglycemia saturates serum

glycated protein

proteins, particularly albumin.

Reference, 300

The life span of albumin is approximately 40 days;

mmolliiter

therefore, this test is performed every 3 wks to

=

excellent diamonitor short-term control of diabetes.

betic control

Sources: Data from JV eorbert (ed). Laboratory Tests and Diagnostic Procedures with

Nursing Diagnoses (5th cd). Upper Saddle River, NJ: Prentice Hall Heahh, 2000; 192-

197; LM Malarkey, ME McMorrow (eds), Nurse's Manual of Laboratory Tesrs and

Diagnostic Procedures. Philadelphia: Saunders, 2000;577-580; and RA Sacher, RA

McPherson, JM Campos (eds). Widman's Clinical Interpretation of Laborarory Tests

(II ,h cd). Phil,delphiao D,vis, 2000;817-818.

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AClJ1'E CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table 11-9. Summary of Insulin Pump T herapy

Patient

Demonstrated ability ro self-monitor glucose Jnd adjust

candidacy

insulin doses based on preprandial blood glucose levels

and anticipated future activity level.

Motivated to achieve and maintain improved glycemic

control using intensive insulin therap}'.

Pregnant padenrs with rype I diabetes.

Patients unaware of hypoglycemic episodes with insulin

therapy.

Patients who experience wide glycemic variations on a

day-co-day basis.

Patients with a significanr rise in hyperglycemia in the

morning ("dawn phenomenon").

Parienrs who need flexibility in their insulin regimen (e.g.,

erratic work schedules, travel frequently).

Adolescents who experience frequent diabetic ketoacidosis.

Night-time usc for children under JO yrs of age who may

nOt be able to adjust their own insulin requirements.

Pump desctiption

Approximately the size of an electronic pager, weighing

only 4 oz.

Padents are instructed on how to insert and change (every

2-3 days) infusion catheters inro rhe subcutaneous

space of their abdomen.

The catheter can be detached from the insulin pump for

bathing or intimate cooract.

Two serrings: basal rate and bolus doses, borh adjustable

by rhe patient depending on needs (e.g., preprandial

boilis or decreased basal rate with exercise).

Battery life is approximately 6 wks.

Types of insulin

Regular human buffered insulin (shorr acting).

Insulin analog (rapid acting).

Pump

Hyperglycemia and diabetic keroacidosis.

complications

Hypoglycemia and hypoglycemic unawareness.

Skin infections.

Weighr gain.

Sources: Data from J Unger. A primary care approach [0 continuous subcutaneous insulin infusion. Clin Diaberes 1999; 17(3): I 13; Conrinuous subcmancolls insulin. Diabetes Carc 2001 ;24( 1 ):598; and FR Kaufman, M Halvorson, C Kim, P Pitukcheew:mollt. Use