Complications of Diabetes

Diabetes mellitus is a chronic, multisystem disease characterized by high blood glucose, or hyperglycemia, which can lead to both acute and chronic complications.

Okay, let’s review the pathophysiology of hyperglycemia. Normally, the beta cells in the pancreas release insulin, which is a hormone that helps glucose move from the bloodstream and into the tissue cells where it can be used for energy.

In diabetes, though, either the pancreas doesn't produce insulin, like with type 1 diabetes, or the body’s cells are resistant to insulin, like with type 2 diabetes.

Either way, hyperglycemia results, causing symptoms like polyuria, or frequent urination; polydipsia, or increased thirst; and polyphagia, or increased appetite.

Now, hyperglycemia can cause two serious acute complications: diabetes-related ketoacidosis, or DKA, and hyperosmolar hyperglycemia syndrome, or HHS.

First, in DKA, glucose levels rise to 250 mg/dL or more, but since the cells are unable to use the glucose, they start breaking down adipose tissue, or fat, as a source of energy; a process called lipolysis.

During lipolysis, ketone bodies are made as a byproduct, which increases the acidity of the blood, leading to metabolic acidosis.

This manifests as deep and labored breathing, also called Kussmaul respirations, and fruity-smelling breath. As excess glucose is eliminated by the kidneys, large amounts of water is pulled along with it, a process called osmotic diuresis.

Dehydration and electrolyte imbalances develop as fluids are depleted. On the other hand, in HHS, glucose levels rise to 600 mg/dL or more.

This results in osmotic diuresis and dehydration that is much more severe than with DKA. But in contrast to DKA, there’s no breakdown of fat, so metabolic acidosis does not occur.

If untreated, DKA and HHS can progress to cerebral edema, coma, and even death. Now, another acute complication is caused by hypoglycemia, or low glucose levels.

Hypoglycemia can occur when there’s an imbalance between insulin and glucose, like when a patient doesn't eat enough, exercises more than usual, or takes too much insulin or antidiabetic medication.

When glucose drops below 70 mg/dL, the body reacts by releasing counterregulatory hormones such as glucagon and cortisol to increase the glucose level; and epinephrine, which activates the autonomic nervous system resulting in shakiness, diaphoresis, palpitations, and anxiety.

Other clinical manifestations are related to a decreased glucose supply to the brain and include blurred vision and confusion.

If untreated, hypoglycemia can progress to seizures, coma, and death. Alright, persistent hyperglycemia can damage blood vessels throughout the body, causing chronic complications.

First, microvascular complications result from damage to small blood vessels, like in the eyes, leading to diabetic retinopathy and vision loss; or in the kidneys, causing renal insufficiency and eventual failure.

Then there are macrovascular complications, which impact the medium and large blood vessels. This can increase the risk of myocardial infarction and stroke, as well as peripheral vascular disease, or PVD.

Neuropathy, where the sensation in the extremities is decreased, can also occur. Neuropathy in the feet increases the risk of developing foot ulcers.

Additionally, autonomic neuropathy can cause gastroparesis, or delayed gastric emptying; urinary retention; and erectile dysfunction.

Now, when caring for your patient with an acute complication of diabetes like DKA or HHS, begin by closely monitoring their glucose levels in their blood and urine.

Administer the prescribed insulin, IV fluids, and electrolytes. For hypoglycemia, follow the “rule of 15” to treat them, which includes giving them 15 to 20 grams of a fast-acting carbohydrate, like fruit juice, and then recheck their blood glucose 15 minutes later.

If their blood glucose is still low, give them another 15 grams of a carbohydrate and then recheck again 15 minutes later.

Continue to monitor your patient closely and evaluate the effectiveness of your interventions. When educating your patient, focus your teaching on lifestyle changes to help them manage their diabetes and prevent complications.

Review their prescribed diabetic diet and remind them of the importance of regular physical activity and maintaining a healthy weight.

Also, talk about protecting their feet by avoiding going barefoot, wearing properly fitting footwear, and inspecting their feet each day.

Finally, encourage your patient to meet with their diabetic educator and keep all follow-up appointments with their health care providers for continued monitoring and care.

Alright, as a quick recap... Diabetes mellitus is a chronic, multisystem disease characterized by hyperglycemia, which can lead to acute complications like DKA, HHS, and hypoglycemia; and chronic complications, like diabetic retinopathy, kidney failure, PVD, peripheral and autonomic neuropathy, and foot ulcers.

Nursing considerations for patients with diabetes are focused on assessment, intervening to restore a normal glucose level, and providing teaching for glucose management to limit complications and improve quality of life.