Exploring the Pathophysiology and Clinical Manifestations

Understanding of the pathophysiology and clinical manifestations of Diabetes

This study will focus on the pathophysiology of the diabetes mellitus conditions and expose the clinical manifestations of the condition. Diabetes mellitus is a medical condition arising from metabolic disorder resulting in hyperglycaemia (Chamberlain et al 2016). This condition is classified into different types depending on the cause of the condition. Type 1 diabetes is caused by immunity deficiencies resulting in the condition. Type 2 diabetes arises from insulin resistance by the body.

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Pathophysiology of diabetic ketoacidocis (DKA)

This study will examine the pathophysiology of diabetes mellitus type 1 with a keen focus on the DKA which is most common in patients with diabetes type 1.

Type 1 diabetes stems from the destruction of the immunity, occurring within the body and affecting the cells in the pancreas that are responsible for the production of insulin (Chamberlain et al 2016). This inhibits the ability of the body to regulate the blood sugar level. This manifestation is evident when there is the presence of immune-competent and accessory cells in the pancreatic cells. The presence of these cells contributes to the inhibition of the insulin production cells. Furthermore, people who contract type 1 diabetes are susceptible to the disease courtesy of the immune response gene that is inhibited due to the major histocompatibility complex created by the presence of insulin inhibiting cells. (Chamberlain et al 2016).

Severe diabetes type 1 may result to the condition known as diabetic ketoacidocis, also referred to as diabetic acidosis or diabetic coma. This condition originates from the body among patients with diabetes type 1 when the breakdown of lipids generates a surplus of acidic ketone bodies. Episodes of DKA are manifested in three different ways which can be used to classify the patients with the condition. Thus, hyperglycaemia, ketosis and metabolic acidosis are the common manifestations among the patients with DKA which is precipitated by deficiencies in the insulin level in the body (Maletkovic and Drexler 2013). Insulin is a crucial element in the management and regulation of blood sugar level in the body. The deficiencies in insulin may stem from a number of factors including illness or infection, insufficient insulin dose to patients with diabetes, and neglect of the treatment regimen prescribed to the patients by the health practitioners specializing in the management and treatment of diabetes (Gosmanov and Wall 2014). Inadequacy of insulin therefore resulting in low levels of glucose forces the cells to convert the subcutaneous fats into fuel necessary for the body functioning. In this case therefore, the acidic components of the subcutaneous fats results in the acidosis, thus the development of DKA.

Manifestations of diabetes

Diabetes mellitus, just like other medical conditions is manifested through some symptoms that are characteristic of people suffering from diabetes. Understanding these symptoms is crucial in helping to pinpoint the condition in its early stage which can aid in effective disease management. Patients with DKA condition exhibit common symptoms such as weight loss, polyuria, constipation, and fatigue (Chamberlain et al 2016). Other manifestations of the condition include polydipsia, polyphagia, cramps, blurred vision, and candidiasis (Chamberlain et al 2016). The manifestation of the symptoms of DKA are widespread in the body and can be felt in the abdomen (abdominal pain), whole body (dehydration, excessive thirst), gastrointestinal tract (nausea), mouth (dryness), respiratory (shortness of breath), and urinary (excessive urination) (Gosmanov & Wall 2014). Therefore, the manifestation of these conditions among patients warrants medical tests to establish or determine the condition of diabetes and which type of condition the patient may be grappling with.

Disease management programs for DKA

The management of diabetes stems from comprehensive proposed aspects that direct the care accorded to patients with diabetes. According to the report by the Parliament UK (2012), diabetes patients continue to develop complications associated with the disease if there is no effective support is provided to the patients to manage the condition. Unlike the other medical complications that can be managed by one type of intervention, DKA condition requires behavioural, dietary, lifestyle and pharmaceutical intervention approaches to effectively manage the condition.

Medical intervention

Patients with diabetes are accorded medical or pharmaceutical interventions based on the nature and severity of their complications. For patients with diabetes ketoacidosis, the most common medical treatment accorded to them is the multiple insulin injections continuously administered to the patients (Savage et al 2012). These injections have the potential of reducing the risk of or the progression of microvascular and cardiovascular complications, which commonly accompany diabetes complications. Insulin and the treatment fluids for the DKA condition are administered intravenously. Intravenous fluids such as saline and insulin are administered to patients to correct hyperglycaemia, electrolyte imbalances and dehydration (Basnet et al 2014). Insulin, as well known helps to reduce glucose level and regulate ketogenesis.

However, patients with DKA often experience more serious complications. In this case, a patient-centred approach in offering medical treatment to the patients has been suggested as an ideal tool for managing the condition. The therapy should consider other aspects such as the efficacy of the treatment dosage, potential side effects of the medication such as comorbidities, hypoglycaemia, and effects on the patient's weight (Chamberlain et al 2016). Furthermore, the medication is also considerate of the patient's preferences commonly known as E rating. The proposed initial medication for the patients with type 2 diabetes is metformin, which has been evidenced to be effective, inexpensive and has reduced risks of cardiovascular events.

Additionally, other medical treatments can be administered to patients with diabetes. These treatments include basal insulin and bolus insulin, commonly known as insulin therapy (Eng et al 2014). Insulin therapy can be administered as dosages in combination with other therapeutic interventions to regulate the blood sugar level depending on the patient’s insulin needs.

Behavioural therapy

This is an approach for the management of diabetes conditions and entails enforcing the behaviours which avoid risky behaviours that could lead to diabetes or further escalate the condition. Lifestyle behavioural therapy is applied to diabetes patients and targets risky behaviours such as smoking (Eng et al 2014). According to Basnet et al (2004) nurses and healthcare professionals play a crucial role in behavioural therapy for diabetes disease management. For instance, patients with diabetes with risky behaviour such as drinking alcohol and smoking should be educated on the implications of their risky behaviour on the prevalence of the diabetes condition. Through the multidisciplinary team, DKA patients will be educated on the ability of the risky behaviours such as alcohol smoking to inhibit the efficacy of the diabetes medication and help from counsellors may help in enhancing behaviour change (Chamberlain et al 2016).

Furthermore, diet is a crucial element in diabetes conditions. Some foods increase the chances of diabetes conditions such as sugary foods which may have an impact on the cardiovascular system of the patients, predisposing the patient to diabetes. The association between diabetes and cardiovascular diseases further emphasizes the need for adoption of dietary intervention in the care and management of patients with diabetes (Nyenwe et al 2016. It is quite common for patients with diabetes to be recommended special food regimens that enhance their health and regulates the blood sugar in the body of the patients. Stability in the blood sugar level is the main attribute to managing the diabetes condition (Nyenwe et al 2016). Thus, by the adoption of a multidisciplinary team approach in caring for diabetes patients, nutritionists will play a crucial role in recommending and educating the patients on the appropriate diet for the management of DKA conditions.

Long term diabetic complications

Diabetes mellitus has been associated with chronic medical conditions if left unmitigated for a long time. These associated complications have the potential of significantly weakening the immunity and health of the patient. The common complications associated with diabetes include microvascular and cardiovascular conditions.

Acute renal failure is a microvascular fatal condition that is commonly associated with end-stage renal infection among patients with DKA (Centre for disease control and prevention 2015). This complication emerges from long term diabetes and requires medical attention to manage the condition. One of the measures of detecting acute renal failure is conducting annual diabetic kidney screening using the urine albumin- creatine ratio.

Foot care

Annual foot examination is crucial for patients with long term diabetes condition that has lasted for over 5 years. This is crucial in identifying infections of the foot that is common among diabetic patients as well as those with diabetic ketoacidosis. In the examination and education for proper foot care, there is a risky individual who should be focused on the screening (Centre for Disease control and prevention 2015). People with a history of foot ulceration, foot deformities, and peripheral neuropathy should be closely monitored to ensure they are well educated on proper foot care

Diabetic ketoacidosis is also associated with cardiovascular complications which are fostered by risk factors such as dyslipidaemia, smoking or a family history of premature coronary disease. Controlling cardiovascular conditions can be crucial in the management of diabetes conditions. The common management strategies for handling cardiovascular complications include hypertension management, lipid management, and antiplatelet agents (Joint British Diabetes Society 2011). These three intervention approaches consist of unique strategies for managing the condition and may result in better management of the diabetic condition.

Multidisciplinary efforts in the management of diabetes

The effective management of the diabetic ketoacidosis conditions depends on the efforts of multidisciplinary teams that are dedicated to providing a comprehensive approach for the management of diabetes and related medical conditions. Multidisciplinary teams can be drawn from different departments and composed of professionals in different fields who team up to share expertise in the care and management of the diabetes condition (TREND-UK 2011).

The provision of care to patients with diabetes has been identified above to take different forms with different strategies bearing different results. According to Diabetes UK (2009) a recommended multidisciplinary approach should compose of professionals drawn from different fields within healthcare and include physician, diabetes specialist nurse, general practitioner, optometrists, practice nurses and pharmacist. The premise of the formation of the multidisciplinary teams is to provide special care for diabetes patients by being integrated into primary care (Diabetes UK 2009). Thus, the patient's when seeking care and treatment for diabetes encounters the team and benefits from a holistic intervention and therapy delivered by the team. This promotes a holistic and faster recovery of the patients (Diabetes UK 2009). According to the recommendations from the NICE (2018), a comprehensive diabetes prevention program should be based on core objectives including developing and integrating strategy to preventing non-communicable disease, addressing key risk factors for the diabetes such as unhealthy diet, understanding and considering the variations in different population subgroups as well as linking the strategies to targets and the outcomes of diabetes prevention.

Nursing function in supporting and promoting self-care

The nurse is a crucial caregiver of the patients living with diabetes condition. The role of the nurse is based on providing education to the patient s with diabetes. Education is a crucial approach to enhancing self-care of the patients. It must be emphasized that the patient's family and relatives play a crucial role in providing care to diabetes patients as well as ensuring that patients with diabetes follow the care and treatment regimen recommended to them by health practitioners (Dorflinger et al 2013). According to Diabetes UK (2009), Effective diabetes self-care require obtaining the information on diabetes, recognising the role of the patient and nurse in health and empowering patients to take personal responsibility for management of diabetes as well as practicing regularly care activities to meet the planned goals. Teaching on self-care is particularly crucial and necessary for patients with DKA (RCN 2010). This teaching seeks to enhance the capacity for better health and is a better patient outcome model for nurses.

The education on self-care can be achieved through DESMOND, DAFNE, and X-PERT models (Diabetes UK 2011). DESMOND model, for instance, stands for diabetes education and self-management for on-going and newly diagnosed and it is a 6-hour education plan that composes of group education and it consists of 6 to 10 newly diagnosed patients of type 2 diabetes (Diabetes UK 2011). The self-care education seeks to train patients on the administration of insulin to the body, having conducted self-assessment for the need of insulin depending on the manifestations of the symptoms. Furthermore, the education also seeks to enhance the knowledge of the family and relatives of diabetes patients to enable them to effectively monitor the progress of the patients, provide care through enhancing the appropriate diet for patients with diabetes is followed and to support and show love to patients with diabetes to enhance their progress and better health (Mills and Stamper 2014). The adoption of the DESMOND training framework by the nursing practitioner also allows for the monitoring of the implementation of the self-care interventions suggested for the patients with diabetes (Diabetes UK 2009). Nevertheless, family members and relatives can be enrolled in the program to learn effective self-care initiatives for diabetes patients. This translates to improved health of the patients and better knowledge for managing the diabetes conditions for the family members of the patients affected.

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References

Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Care Statistics. 2014: Crude and age adjusted hospital discharge rates for major cardiovascular disease as first-listed diagnosis per 1,000 diabetic population, United States, 1988–2006. Atlanta, GA: Centers for Disease Control and Prevention; Accessed at www.cdc.gov/diabetes/statistics/cvdhosp/cvd/fig3.html.

Chamberlain J, Reinhart A, Sheafer C, and Neuman A. 2016. Diagnosis and Management of Diabetes: Synopsis of the 2016; American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med.164:542-552. doi:10.7326/M15-3016

Chua HR, Schneider A, Bellomo R. 2013. Bicarbonate in diabetic ketoacidosis - a systematic review. Ann Intensive Care; 1(23).

Diabetes UK 2011: Diabetic ketoacidosis (DKA). http://www.diabetes.org.uk/MyLife-YoungAdults/Treatment-and-care/Diabetic-ketoacidosis-DKA/.

Diabetes UK. 2009. Diabetes care and you; what diabetes care you can expect. London.

Dorflinger L., Kerns R.D. & Auerbach S.M. (2013) Providers' roles in enhancing patients' adherence to pain self-management. Translational Behavioural Medicine 3(1), 39–46.

Eng C, Kramer CK, Zinman B, Retnakaran R. 2014: Glucagon-like peptide-1 receptor agonist and basal insulin combination treatment for the management of type 2 diabetes: a systematic review and meta-analysis. Lancet.; 384:2228-34. [PMID: 25220191] doi:10.1016/S0140-6736(14)61335-0

Gosmanov AR, Wall BM. Diabetic ketoacidosis. In: Bope ET, Kellerman RD, editors. Conn’s Current Therapy. Philadelphia, PA: Elsevier Saunders; 2014. 2014. pp. 710–713

Joint British Diabetes Societies Inpatient Care Group 2011, The Management of Diabetic Ketoacidosis in adults, accessed from: http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf

Mills LS, & Stamper JE 2014. Adult diabetic ketoacidosis: Diagnosis, management and the importance of prevention. Journal of Diabetes Nursing 18: 8–12

NICE. 2018. National strategy and policy to prevent type 2 diabetes. National institute for health and care excellence. http://pathways.nice.org.uk/pathways/preventing-type-2-diabetes

Nyenwe, E.A. and Kitabchi, A.E., 2016. The evolution of diabetic ketoacidosis: an update of its etiology, pathogenesis and management. Metabolism, 65(4), pp.507-521.

Parliament UK. 2012. Department of Health: The management of adult diabetes services in the NHS. House of Commons committee of public Accounts, London

Royal College of Nursing 2010. Clinical Nurse Specialist: Adding Value to Care – an executive summary. RCN, London. Available at: http://bit.ly/K19w1x (accessed 07.01.14)

Savage MW, Dhatariya K, Kilvert A, Courtney H, Hammersley M, Rees A et al. 2012. Response to Taylor. Insulin dose requirement in diabetic ketoacidosis. Diabetic Med; 29(1):153-154.

TREND-UK 2011. An integrated career and competency framework for diabetes nursing (3rd edition). TREND-UK, SB Communications Group, London. Available at: http://bit.ly/1iNGu4Q

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