Definition
A.Due to autoimmune destruction of the pancreatic beta cells.
B.Previously referred to as insulin-dependent diabetes or juvenile-onset diabetes.
C.Further divided into two subgroups based on pathogenesis.
1.Immune-mediated diabetes.
a.Autoimmune-mediated destruction of pancreatic beta cells.
b.Often have other autoimmune disorders such as Hashimoto’s thyroiditis, Graves’ disease, Addison’s disease, celiac disease, vitiligo, autoimmune hepatitis, myasthenia gravis, and pernicious anemia.
2.Idiopathic type 1 diabetes.
a.No known etiologies.
b.Permanent insulinopenia and prone to ketosis.
c.No evidence of autoimmunity.
d.African or Asian ancestry.
e.Strongly inherited; no human leukocyte antigen association.
Incidence
A.In 2012, approximately 1.25 million American children and adults had type 1 diabetes.
B.Worldwide incidence is increasing by approximately 3% per year.
Pathogenesis
A.Autoimmune destruction of pancreatic beta cells; 85% of type 1 diabetes patients have detectable circulating antibodies.
B.Rate of beta cell destruction can vary.
1.Rapid in infants and children.
2.Slow in adults.
Predisposing Factors
A.Presence of other autoimmune diseases.
B.Family history of diabetes.
C.Viruses.
D.Environmental toxins.
Subjective Data
A.Common complaints/symptoms.
1.Polyuria (96%).
2.Polydipsia.
3.Weight loss.
4.Fatigue.
B.Common/typical scenario.
1.Patients frequently complain of fatigue and weakness. They may have muscle cramps, blurred vision, and significant polyuria, polydipsia, and polyphagia.
2.Weight loss occurs over time despite normal or increased appetite.
C.Family and social history.
1.Ask about family history since there is a strong link to family history.
2.Ask about type of occupation, if the person is a shift worker, use of alcohol, smoking, or recreational drug use.
3.Review how much exercise the person gets.
D.Review of symptoms.
1.HEENT.
a.Dental issues. Periodontal disease is associated with diabetes.
2.Psychologic.
a.Depression.
b.Anxiety.
c.Disordered eating.
d.Psychosocial barriers/support.
e.Barriers to self-management.
3.Microvascular complications.
a.Neuropathy.
b.Nephropathy.
c.Retinopathy.
4.Macrovascular complications.
a.Coronary artery disease.
b.Cerebrovascular disease.
c.Peripheral arterial disease.
Physical Examination
A.Height, weight, body mass index (BMI), waist circumference.
B.Vital signs.
C.Funduscopic examination.
D.Thyroid palpation.
E.Skin examination.
1.Acanthosis nigricans (see Figure 8.1).
2.Lipohypertrophy.
3.Diabetic dermopathy.
4.Skin tags.
F.Foot examination.
1.Inspection, noting mycotic changes to nail or skin.
2.Vascular examination.
a.Hair patterns or lack of hair growth.
b.Pulses (dorsalis pedis and posterior tibial).
c.Temperature/color.
3.Reflexes.
a.Patellar.
b.Achilles.
4.Proprioception, vibration, and monofilament sensation.
Diagnostic Tests
A.Glycosylated hemoglobin (HgbA1C), fasting glucose, random glucose, or 2-hour glucose tolerance test to diagnose.
1.HgbA1C greater than 6.5%.
2.Fasting glucose greater than 126 mg/dL.
3.Random glucose greater than 200 mg/dL with classic symptoms of hyperglycemia.
4.2-hour glucose tolerance test greater than 200 mg/dL.
B.Antibodies to check at time of diagnosis.
1.Glutamic acid decarboxylase (GAD).
2.Islet cell antibodies.
3.Zinc antibodies.
C.HgbA1C on admission to hospital if no result available for past 3 months.
D.Yearly lab work.
1.Fasting lipid panel.
2.Liver function tests.
3.Urine albumin-to-creatinine ratio.
4.Serum creatinine and estimated glomerular filtration rate (GFR).
5.Thyroid-stimulating hormone.
E.C-peptide and random glucose to determine insulin production by beta cells.
Differential Diagnosis
A.Steroid-induced diabetes.
B.Pancreatitis.
C.Cushing’s disease.
D.Pancreatic endocrine tumor.
E.Gestational diabetes.
F.MODY type diabetes.
G.Latent autoimmune diabetes in adults (LADA).
H.Type 2 diabetes.
I.Cystic fibrosis-related diabetes.
J.Posttransplant diabetes.
K.Postpancreatectomy diabetes.
Evaluation and Management Plan
A.General plan. The recommended outpatient comprehensive treatment plan for type 1 diabetes according to the American Association of Diabetes Educators consists of the following seven self-care behaviors.
1.Healthy eating: The patient should see a registered dietician for medical nutrition therapy counseling.
2.Being active: At least 150 minutes of moderate to vigorous intensity physical activity spread out over a week is required. This can include resistance exercises and flexibility exercises.
3.Monitoring: It is recommended to test glucose before meals and bedtime (more if needed).
4.Medications (insulin).
a.Delivery method options: Pens, vial and syringe, pump.
b.Regimen choices (premixed insulin vs. basal and prandial).
c.Proper storage of insulin.
d.Preparation, administration, and site rotation of insulin injection.
e.Disposal of sharps.
f.Hypoglycemia symptoms.
5.Problem solving.
6.Healthy coping.
7.Reducing risks.
B.Patient/family teaching points.
1.Inpatient education focuses on survival skills only.
a.Checking glucose.
b.Taking medications.
c.Diet.
d.Hypoglycemia treatment.
FIGURE 8.1 Acanthosis nigricans is a dark, velvety, hyperpigmentation of the skin, often found at the skin folds.
Source: Lyons, F., & Ousley, L. (2015). Dermatology for the advanced practice nurse (p. 55). New York, NY: Springer Publishing Company.
2.Outpatient education is more comprehensive and uses guidelines by the American Association of Diabetes Educators to direct the education. The patient should be referred to outpatient diabetes education at the time of diagnosis, yearly thereafter, and as needed or if therapy changes.
C.Pharmacotherapy.
1.Insulin: Mainstay of therapy.