Diabetes Reflective Essay Introduction

Introduction

Diabetes (or Diabetes mellitus) is a complex group of diseases caused by a number of reasons. Individuals suffering from diabetes have hyperglycemia (high blood sugar) either because there is low production of insulin or body cells do not use the produced insulin. About 350 million people suffer from diabetes globally (Danaei et al., 2011). The World Health Organization (1999) has predicted that diabetes will rise to the top seventh cause of death worldwide by 2030. There are three common forms of diabetes: type 1 diabetes, type 2 diabetes and gestational diabetes. This paper mainly discusses these major forms of diabetes considering their causes and consequences.

Type 1 Diabetes

In type 1 diabetes mellitus, body cells fail to produce insulin due to a compromised immune system causing damage to the cells where production of insulin takes place. The cause and prevention of type 1 diabetes are not particularly known; however, it is suspected to be a consequence of certain genetic factors.

Type 2 Diabetes

In type 2 diabetes mellitus, there is low production of insulin by the body cells or the body does not effectively make use of the produced insulin. Type 2 diabetes is known to be the commonest type of diabetes; in fact, 90% of diabetes sufferers have type 2 diabetes (World Health Organization, 1999). The cause and cure of type 2 diabetes remains unknown; however, genetic factors and manner of living take part in its causes, and watching blood sugar level can control the disease.

Gestational Diabetes

Gestational diabetes happens when there is a development of high blood sugar level in pregnant women not previously diagnosed of diabetes. For mothers who had gestational diabetes during their first pregnancy, the probability that it will occur in subsequent pregnancies is approximately two-thirds. Furthermore, some patients may subsequently develop type 2 diabetes. After pregnancy, diabetes type 1 or 2 may occur and will require obligatory treatment.

Genetic Factors and Markers

The role of genetic factors as a cause of diabetes has been proven definitively. This is the main etiological factor for diabetes.

IDDM is considered to be a polygenic disease which is based on at least two of the mutant genes in diabetic chromosome 6. They are associated with the HLA system (D-locus), which determines the individual, genetically determined response of the body and B cells to various antigens.

The hypothesis of polygenic inheritance of IDDM suggests that diabetes is caused from two mutant genes (or two groups of genes) that have a recessive inherited predisposition to autoimmune lesions of the insular apparatus or increased sensitivity of B cells to viral antigens or attenuated antiviral immunity.

Genetic susceptibility is linked with particular genes of HLA systems, which are considered markers of such a predisposition.

Patients with a genetic predisposition to IDDM have an altered response to environmental factors. They have weakened antiviral immunity, and they are extremely susceptible to cytotoxic damage to the B cells by viruses and chemical agents.

Viral Infection

Viral infection may be a factor that provokes the development of IDDM. The most common occurrence of IDDM clinically is preceded by the following viral infections: measles (rubella virus has a tropism to the islets of the pancreas, accumulates, and can be replicated in them), Coxsackievirus and hepatitis B virus (can be replicated in the insular apparatus), mumps (1-2 years after the epidemic of mumps, the incidence of IDDM in children dramatically increases), infectious mononucleosis, cytomegalovirus, influenza virus, etc. The role of viral infection is confirmed by seasonality in the incidence of IDDM development (often, the first diagnosed cases of IDDM among children occur in autumn and winter months, with a peak incidence in October and January), the detection of high titers of antibodies to the virus in the blood of patients with IDDM, and the detection by immunofluorescent methods for studying viral particles in the islets of Langerhans in people who have died of IDDM. The role of viral infections in the development of IDDM is confirmed in experimental studies. Viral infections among individuals with a genetic predisposition to IDDM are involved in the development of the disease as follows:

  • the cause of acute injury to B cells (Coxsackievirus);
  • leads to viral persistence (congenital cytomegalovirus infection, rubella) with the development of autoimmune reactions in the islet tissue.

In modern diabetology, the next staging of IDDM is expected.

First stage – a genetic predisposition, due to the presence of certain antigens in the HLA system, as well as genes of chromosomes 11 and 10.
Second stage – the initiation of the autoimmune process in islands of B cells influenced with viruses, cytotoxic agents and any other unknown factors. A crucial point in this step is the expression of B cells HLA-DR-antigen and glutamic acid, and therefore, they become autoantigens that cause the development of autoimmune response reactions.
Third stage – the stage of the active immunological process with formation of antibodies to B cells, insulin and autoimmune insulitis development.
Fourth stage – the progressive reduction of insulin secretion stimulated by glucose (1-phase secretion of insulin).
Fifth stage – clinical diabetes (the manifestation of diabetes). This step develops during the occurrence of the degradation and death of 85-90% of the B cells.
Many patients after the insulin treatment fall into remission of the disease (the “diabetic honeymoon”). Its length depends on the severity and degree of B cell damage, their ability to regenerate, and the level of residual insulin secretion, as well as the severity and frequency of related viral infections.
Sixth stage – the complete destruction of b-cells, and a complete lack of insulin secretion and C-peptide. Clinical signs of diabetes form and insulin treatment becomes necessary again.

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Gestational diabetes
Introduction
     Diabetes Mellitus is an endocrine disorder that effects insulin production. It is a syndrome characterized by chronic hyperglycemia and improper metabolism of nutrients (McCance, 2002). Improper metabolism is related to the inability of the pancreas to produce enough insulin facilitate glucose movement into the cells. Insulin is the determining factor that allows glucose to enter the cells. Therefore, glucose remains in the blood stream and causes hyperglycemia to occur (Olds, 2000). Gestational diabetes is the occurrence of diabetes during pregnancy. Approximately seven percent of all pregnancies are complicated by gestational diabetes (American Diabetes Association, 2002).
     This topic was chosen out of curiosity as well as the need to gain knowledge of this disease. Diabetes is complicated in itself and gestational diabetes is a more acute risk that entails two lives instead of one. It is a disease that requires careful monitoring of both mother and child to ensure a safe pregnancy. Although some women have diabetes before becoming pregnant, the purpose of this paper is to further explore diabetes that is acquired during pregnancy.
Pathophysiology and Detection
     As stated above, diabetes mellitus is related to the inability of the pancreas to produce enough insulin. In the case of gestational diabetes, the cause of the increased demand for insulin is related to the fetus. The fetus receives insulin from the mother, therefore pregnancy drastically alters the insulin demand.
     

Increased insulin requirements usually begin late in the first trimester as glucose and glycogen stores begin to be depleted. Signs and symptoms can range from glucosuria, ketonuria and polyuria to no symptoms at all (Shaw, 2000).
     Detection is the single most important factor in managing a woman with gestational diabetes. Risk assessment should be performed during 24-28 weeks gestation. Women at a greater risk for contracting gestational diabetes include those with a history of gestational diabetes, obesity, glycosuria or a family history of diabetes. These women need to be assessed for diabetes at the first prenatal visit and if no symptoms are present, they need to be screened a second time at 24-28 weeks gestation (American Diabetes Association, 2000).
     Screening begins with a urinalysis to detect the presence of glucose or ketones in the urine. A glucose challenge test is also performed. This test involves a blood glucose test that is taken one hour after ingestion of 50 grams of oral glucose. If her blood sugar level is greater than 140, further testing is necessary (McFarland, 1997).
     If a client does not ‘pass’ the glucose challenge test, a glucose tolerance test is completed to either rule out or diagnose gestational diabetes. This is a three hour, 100 gram oral glucose test. The woman eats a high carbohydrate diet for three days before her test. She is then instructed to fast for 8-14 hours. The morning of the test, she ingests 100 grams of glucose. The plasma glucose is taken first at fasting, then one, two and three hours after ingestion of the glucose. Actual diagnosis of gestational diabetes occurs if two or more of the following results are positive: ·     Fasting with blood glucose >105
·     1 hour glucose level >190
·     2 hour glucose level > 165
·     3 hour glucose level > 145 (Olds, 2000).
Pharmacological and Non-pharmacological Treatments
     Both pharmacologic and non-pharmacologic measures are taken to manage care of a woman with gestational diabetes. Nutrition counseling, exercise and insulin administration (if necessary) are the three major interventions used.
     In a study done in 2001, it was found that light exercise following meals could help control blood glucose and potentially avoid insulin therapy. Light exercise with an increased heart rate of nine beats per minute is recommended in patients that do not have a medical or obstetrical contraindication (Garcia-Patterson, 2001).
     Nutrition is probably the most important factor in trying to manage gestational diabetes. It is possible to control glucose levels with diet alone. Counseling by a diabetic educator or dietician is strongly encouraged. If this is not feasible, caloric intake and monitoring should be taught to the patient. A diet should be well balanced with a reduction of ‘sweets’. A pregnant woman needs about 300 more calories a day compared to a non-pregnant woman. These calories should be divided into small, frequent meals and include both complex carbohydrates and proteins to prevent hypoglycemia during the night (McFarland, 1997). Monitoring blood glucose is also essential in determining the diet. It can aid in assessing the effect of the patients diet and let the patient know when to regulate her blood sugar.
     
If a client is unable to control her diabetes by diet, insulin must be initiated. As pregnancy progresses the demand for insulin becomes greater. A typical insulin regimen begins with small doses of intermediate and/or regular insulin. This amount is adjusted throughout pregnancy as insulin resistance increases. Oral glucose lowering agents are not recommended in pregnancy because their safety has not yet been established (McFarland, 1997).
Nursing Interventions
     As a nurse, it is important to encourage compliance to diet and exercise to try and prevent the use of insulin. Teaching is a critical role the nurse plays in the case of gestational diabetes. The more educated the patient, the better the chance she has of managing and even controlling her disease and ensuring the safety of her child. Fetal evaluation during pregnancy is essential as well. An ultrasound is typically done at 18 weeks gestation and again at 28 weeks. Non-stress tests are also performed at 28 weeks. Evaluation of maternal blood glucose levels is also a responsibility of the nurse. Postpartum women usually have a drastic decrease in insulin requirements. Assessment for hypoglycemia and establishing a safe glucose level after birth are priority for the nurse (Olds, 2000). As with all pregnancies, gestational diabetes or not, maternal-child bonding is another priority for the nurse.
Risk to the Fetus
     There are many risks to the fetus in a woman who is diagnosed with gestational diabetes. These risks have been directly related to the disease. Congenital anomalies and severe maternal ketoacidosis put a fetus at risk for death. The anomalies are often related to the nervous, cardiac and skeletal systems. Some infants are born LGA, large for
gestational age, which results from increased levels of glucose crossing the placenta. This case is commonly known as macrosomia. Intrauterine growth restriction is another common problem in babies of gestational diabetes. Other complications related to the fetus include respiratory distress syndrome, hyperbilirubenemia and hypocalcemia (Olds, 2000).
Impact on Family
     The impact on the family depends on the severity of the outcome. If death is a result of complications from gestational diabetes, the entire family is affected. These families need special attention from the nurse and medical staff. Although the situation may only last a few moments, the death of a child will be with the family forever. Resources out of the hospital such as counseling should be recommended and appropriate information should be given.
     Gestational diabetes probably has the greatest impact on the mother simply because she has to change her entire lifestyle in order to protect herself and her child. The family may be impacted by the emotional changes of the mother as well as lifestyle changes (i.e. diet). There may have to be an increase in support due to the stress that is created with a high-risk pregnancy.
Conclusion
     Women that do end up with gestational diabetes are at a higher risk to develop diabetes mellitus after pregnancy. It is important to monitor for signs and symptoms

related to diabetes postpartum. Although gestational diabetes is a common complication of pregnancy, it has an encouraging outcome if it is detected early and appropriate interventions are taken. The primary goal of a nurse caring for a mother with gestational
diabetes is to ensure the appropriate care of her and safe passage her child throughout pregnancy and birth.

     


References


American Diabetes Association. (2002). Gestational diabetes mellitus. Diabetes Care, 25(1), S94.

Garcia-Patterson, A.; Martin, E.; Ubeda, J.; et. al. (2001). Evaluation of Light Exercise in the Treatment of Gestational Diabetes. Diabetes Care, 24 (11), 2006.

McFarland, K.; Pasui, K. (2002). Management of Diabetes in Pregnancy. American Family Physician, 55 (8), 2731.

Olds, S., London, M., Ladewig, P. (2000). Maternal-Newborn Nursing. (6th ed.) New Jersey: Prentice Hall Health.

Shaw, M. (Ed.). (2000). NCLEX-RN Review Made Easy. Pennsylvania: Springhouse Corporation.

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