• Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia resulting from impaired insulin secretion

Classification of Diabetes

I. Type 1 Diabetes

1. Insulin- dependent diabetes mellitus
2. Juvenile- onset diabetes

Characteristics of Type I Diabetes

• Hypoinsulinemia
• 10% of diabetes case
• Patient require insulin
• Age onset is childhood
• Ketoacidosis

Etiology of Type I Diabetes

• Autoimmune disease
• Selective destruction of beta cells by T cells
• Several circulating antibodies against beta cells
• Cause of autoimmune attack
• Both genetic and environmental factor are important

II. Type 2 Diabetes

• Non- insulin- dependent diabetes mellitus
  Adult- onset diabetes

Characteristics of Type 2 Diabetes

• Impaired insulin action
• Insulin secretion is normal or increased
• 90% 0f diabetes cases
• Age of onset is adulthood
• Associated with obesity
• Ketoacidosis but rare
• Most cases don’t require insulin

Etiology of Type 2 Diabetes

• Response to insulin is decreased
• The mechanism of insulin resistance is unclear
• Both genetic and environmental factor are responsible
• Post insulin receptor defect

Mechanism of hyperglycemia in diabetes

1. Increase in hepatic glucose output

• Decrease insulin secretion in Liver
• Decrease homeostatic effect on glucagon secretion resulting in increased glucagon
• Gluconeogenesis and glycogenolysis occurs in Liver
• Results in increased plasma glucose

2. Decrease in uptake of glucose in Muscles

• Decrease in insulin in muscles
• Decreased uptake of glucose and amino-acids in muscles
• Increased breakdown of proteins
• Results in increased plasma glucose and plasma amino acids

3. Decrease in uptake of glucose in adipose tissue

• Decrease in insulin
• Increased lipolysis and decreased lipogenesis
• Results in increased plasma fatty acids

Sign and symptoms of Diabetes

• thirst and frequent drinking
• most frequent urination particularly at night
• unexplained weight loss
• fatigue
• blurred vision
• frequent infection of skin, genital

Diagnostic evaluation of Diabetes

• history taking
• physical examination
• symptoms + random plasma glucose > 11.1 Mm (200mg/ dl )
• fasting plasma glucose >7Mm (126mg/dl)
• oral glucose tolerance test (OGTT) 2 hour plasma glucose >11.1Mm (200mg/dl)

Management of Diabetes mellitus

1. Medical management of Diabetes

Type 1 Diabets

• insulin injection should be given as per needed by analyzing blood sugar level
• frequent blood sugar check
• carbohydrate counting should be done

Type 2 Diabetes

• 7,5 % monotherapy ( metformin unless contraindicated)
• 5 – 9,0% dual therapy ( metformin + other medication)
• If the patient have diabetic complication then we must go for insulin therapy
• As Metformin is contraindicated in-case of renal failure, liver, or lung disease

2. Surgical management of Diabetes

• Gastric bypass and biliopancreatic diversion
• Pancreatic transplantation
• Islet cell transplantation

3. Nursing management of Diabetes

1. Nursing assessment of Diabetes A

• History taking, history of family and past medical history
• Past surgical history and other treatment
• Information about medication and insulin therapy
• Assessment of nutritional status
• Assess the blood sugar level
• Assess for sign and symptoms

2. Nursing diagnosis of Diabetes

• Imbalanced nutrition less than body requirement related to reduction of carbohydrate metabolism due to insulin deficiency
• Fluid volume deficit related to polyuria, decreased fluid intake
• Impaired skin integrity related to decreased sensory sensation, impaired circulation
• Risk for infection related to high glucose level reduction in leukocyte function
• Deficit knowledge about the disease the process related to lack of information

3. Nursing intervention of Diabetes

• Monitor vitals sign of the patient
• Provide medication as per cardex , administer insulin or an oral anti diabetic drug
• Analysis blood glucose level
• Maintain fluid and electrolyte balance
• Increase knowledge about diabetes management
• Monitoring and managing potential cmplications
• Provide skin care especially to the feet and legs
• Assist the client for coping mechanism
• Teach patient self- care and about disease condition

Complications of Diabetes mellitus

1. Acute complications of Diabetes

• Glucosuria ( glucose appear in urine)
• Polyuria( frequent urination)
• Polydipsia( excessive thirst)
• Polyphagia(excessive food intake)
• Ketoacidosis

2. Chronic complications of Diabetes

• Neuropathy ( loss of sensation due to damage of nerve fibres )
• Retinopathy ( damage of retina)
• Cataract ( damage of lens)
• In cardiovascular there may be atherosclerosis, hypertension, myocardial infraction
• In nephropathy there may be severe kidney failure and follow- up proteinuria

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It is the condition caused by excessive production of cortisol for a long period of time, which occur more often in age between 20-40 years of age and have three time higher frequency in women than in men.

CAUSES OF CUSHING SYNDROME

• It is caused by the long term use of steroid drugs
• Also occur from over production of cortisol by the adrenal gland

TYPES OF CUSHING SYNDROME

1. PITUTARY CUSHING SYNDROME

• About 60-70% cases of Cushing syndrome are caused by excessive secretion of Adenocorticotropic hormone (ACTH) due to a lesion in the pituitary gland, most common a corticotroph adenoma
• It is characterized by bilateral adrenal cortical hyperplasia and elevated ACTH level
• This cases show therapeutic response on administration of high doses of dexamethasone which suppresses ACTH secretion and causes fall in plasma cortisol level

2. ADRENAL CUSHING SYNDROME

• Approximately 20-25% cases of Cushing syndrome are caused by disease in one or both adrenal gland
• These include adrenal cortical adenoma, carcinoma and less often cortical hyperplasia
• The group of cases is characterized by low serum ACTH levels and absence of therapeutic response to administration of high dose of glucocorticoid

3. ECTOPIC CUSHING SYNDROME

• About 10-15% of cases have an origin in ectopic ACTH elaboration by non-endocrine tumors
• Most often tumor is an oat cell carcinoma of the lung but other lung cancers and pancreatic tumor have also been implicated
• The plasma ACTH level is high in these cases and cortisol secretion is not suppressed by dexamethasone administration

4. LATROGENIC CUSHING SYNDROME

• Prolonged therapeutic administration of high dose of glucocorticoids or ACTH may result in Cushing syndrome e.g.; in organ transplant recipient and in autoimmune disease
• These cases are generally associated with bilateral adrenocortical insufficiency

CLINICAL FEATURES OF CUSHING SYNDROME

• Central or truncal obesity contrasted with relatively thin arms and leg, buffalo hump due to prominence of fat over the shoulder and rounded oedematous moon-face.
• Increases protein breakdown resulting in wasting and thinning of the skeletal muscles
• Atrophy of the skin and subcutaneous tissue with formation of purple striae on the abdominal wall
• Osteoporosis and easy breakable of the thin skin to minor trauma
• Systematic hypertension is present in 80% of cases because of associated retention of sodium and water
• Impaired glucose tolerance and diabetes mellitus are found in about 20% cases
• Amenorrhea hirsutism and infertility in many women
• Insomnia depression confusion psychosis

DIAGNOSIS OF CUSHING SYNDROME

• History taking
• Physical examination
• Ct scan
• Ultrasonography
• Corticotropin releasing factor CRF stimulation test
• Dexamethasone suppression test
• Blood test
• X-rays of the skull

MANAGEMENT OF CUSHING SYNDROME

1. MEDICAL MANAGEMENT

• Dopamine- agonist cabergoline
• Somatostatine- analog pasireotide
• Steroidogenesis inhibitors like ketoconazole, metyrapone
• Glucocorticoid receptor directed drug like mifepristone

2. SURGICAL MANAGEMENT

• Transsphenoidal adenomectomy can be done

3. RADIATION THERAPY

• If the disease is not controlled with surgery then conventional external beam or stereotactic radiosurgery are effective in controlling cortisol level and also tumor growth in many cases

4. NURSING MANAGEMENT

I. ASSESSMENT

• Enlarged abdomen should be assessed
• Striae over the abdomen and buttocks round face and facial hair should be assessed
• Vitals sign should be monitored
• Monitor neurological status
• Fluid volume level

II. NURSING DIAGNOSIS

• Fluid volume excess related to sodium retention causing edema and hypertension
• Impaired skin integrity related to altered and edema
• Self- care deficit related to muscle wasting and fatigue
• Anxiety related to surgery
• Self- esteem disturbance related to altered physical appearance
• Risk for injury related to surgical procedure

III. GENERAL NURSING MANAGEMENT

• Monitor vitals sign
• Administer medications per cardex
• Weight should be taken every morning
• Use 3% NaCl infusion carefully
• Monitor and analysis all the lab report
• Skin care and oral care should be done strictly
• Monitor neurological status to detect any changes
• Encourage for low sodium diet
• Orally intake of water should be done
• Monitor the surgery site and prevent infection
• Give teaching to patient and visitors for long term monitoring for sign and symptoms of tumor recurrence

COMPLICATIONS OF CUSHING SYNDROME

Untreated Cushing’s syndrome complication include

• Diabetes
• Enlargement of any tumors
• Fractures due to osteoporosis
• Hypertension
• Renal stone
• Any serious infection

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What is COPD?

• Chronic obstructive pulmonary disease COPD are commonly used clinical terms for a group of pathological condition in which there is chronic, partial or complete obstruction, to the airflow at any level from trachea to the smallest airway resulting in functional disability of the lungs.
• The following 4 disease condition are included in COPD
  • Chronic bronchitis
  • Emphysema
  • Bronchial asthma
  • bronchiectasis
• In COPD, less airflow in and out of the airways because of one or more of the following
  • the airway and the air sacs lose their elastic quality
  • the walls between many of the air sacs are destroyed.
  • The wall of the airways become thick and inflamed.
  • The airways makes more mucus than, usual which tend to clog them.

What are the causes of COPD?

Causes of COPD

• Long term exposure to lung irritant that damage the lungs and the airway
• Most common irritant that cause COPD is cigarette smoke
• Exposure to fumes from burning fuel
• People with asthma
• In rare case, a genetic condition called alpha-1antitrypsin deficiency may cause

What are the risk factors of COPD?

Risk factor of COPD

• People who smoke or are exposed to smoke.
• Family history of COPD are more likely to develop the disease if they smoke.
• Long-term exposure to other lung irritant also is a risk factor.
• Almost 90% of COPD death occur in low and middle income countries, where effective strategies for prevention and control are not always implemented or accessible.

Sign and symptoms of COPD

• Feeling of oxygen deprive
• Breathlessness
• Sputum mix with saliva and mucus and may be clear, white, yellow, or greenish
• Chest tightness
• Trouble taking a deep breath
• Unintended weight loss in later stage
• Frequent chest infection
• Wheezing

Diagnosis of COPD

• History taking
• Physical examination
• Spirometry to measure how much air a person can exhale and inhale and how fast air can move into.
• Chest x-ray
• CT scan of chest

How can you manage COPD in hospital?

There are 3 ways to manage COPD
1. Medical management
2. Surgical management
3. Nursing management

MEDICAL MANAGEMENT

• Inhaled bronchodilator
• Β-agonists ( relax bronchial smooth muscles and increase mucociliary clearance)
• Anticholinergic that relax bronchial smooth muscle through competitive inhibition of muscarinic receptor ( M1, M2, M3)
• Oxygen therapy
• Corticosteroid and Nonsteroidal anti-inflammatory drug (NSAID)
• Palliative measure such as regular exercise, good nutrition, flu and pneumonia vaccines

SURGICAL MANAGEMENT

• Lung volume reduction surgery: to remove damage lung tissue
• Bullectomy: removal of large bullae that does not contribute to gas exchange or responsible for complications
• Lungs transplant: to improve health status, functional capacity but does not prolong survival in selected patient with very severe COPD

NURSING MANAGEMENT

Assessment 

• History of smoking, family history, occupational history
• Arterial Blood gas (ABG) analysis
• Respiratory rate, depth and characteristics
• Sputum amount and type
• Anxiety level of the patient
• Inspect the use of accessory muscle during respiration and use of abdominal muscle during expiration

Nursing Diagnosis

• Ineffective breathing pattern related to chronic airflow limitation
• Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection
• Risk of infection related to compromised pulmonary function, retained secretions and compromised defense mechanisms
• Imbalanced nutrition less then body requirement related to increased work of breasting, presenting dyspnea and drug effect
• Deficient knowledge of self-care strategies to be performed at home

Intervention 

• Monitor vitals and general condition of the patient
• Give medication as per cardex
• Monitor pulse oxymetry
• Monitor lung sound every 4 to 8 hours
• Perform chest physiotherapy
• During acute episodes, open door and curtains and limit the numbers of people in the room
• Encourage the use of breathing retraining and relaxation technique
• Give sedative and tranquilizer with extreme caution
• Assess skin color and temperature
• Keep the patient in flowers position
• Advice the patient to drink at least 8 to 10 glasses of fluid per day unless contraindicated
• Asses the condition of oral mucus membrane and provide oral care
• Provide knowledge about disease condition and progress
• Provide proper nutrition aids in the prevention of secondary respiratory infection
• Encourage smoking cessation if applicable

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