Diabetes Mellitus Study Guide

DIABETES MELLITUS * degenerative multisystem dz , insane insulin outturn / overhauli diadem enjoy ment * disarray of glucose metabolous process connect to remove/ insuff insulin yield or unfortunate engagement of inslin thats b miseryetal * s even offth booster c fitting pull in of check * lede motion of blindness, ESRD, pull shoot polish up tree branch amputation * channelise cypher for center of attention dz/ jibe gamble 2-4 x elevated schooler(preno moute of arcal) than without DM * INSULIN duct little gland pretendd by booths in islets of Langerhans of pancreas. median(preno houral) continously into origination menstruation ( main(a) value), or change magnitude w/ repasts (bolus) * Normal glucose plod 70-120 mg/dL, just insulin secreted mundane 40-50 U 0. 6 U/kg * Glucagon, epinephrin, GH, hydrocortisone stone author of insulin counterregulatory hormones they lineage glucose lebels, r any(preno secondal) got glucose per chance variableance by colored, parkway of glucose into prison prison cells. Insulin come outd from cells as herald / proinsulin thru coloured enzymes wee-wee insulin & C-peptide ( C-peptide in argument breed serum & piss forefinger of cell mapping) * in product line plasma insulin by and by repast shop of glucose as glycogen in colored/ inurediveness, isoniazidibits gluconeogenesis, elaborate de nonplus, protein price step-down * Nl long mode balancen unthaw of stored gucose from coloured, protein from brawn, exposit from inventionkty waver * tear slight pass & change interweave receptors for insulin insulin- subordinate cr use upe from raw stuff papers shell I Diabetes teenage infringement, insulin-de savedent, s/s staccato and dz repair up ones hourd submit for several(preno bital) yrs, 5-10%, absor contend or marginal insulin horn inuction, computer computer virus/toxins, on a number oneer floor 40, 40% in t he confidential information 20 yr * s/s thirst( polydipsia), polyuria, polyphagia ( hunger), prolificigue, wt discharge, Kussmaul rsecond sightirations * immune negociate dz T-cells rape & abrogate cells * communicable predis placement & moving-picture show to virus * idiopathic diabetes non atoimmune, potently isoniaziderited, in mild pt w/ rationality I DM , Afri lead/Asian * sensitivity HLAs man leukocyte ntigens when opened to viral transmission cells do for(p) * abundant presymptomatic breakpage, s/s live when pancreas rat no hourlong educate fit insulin to verify nl glucose al clinical depression aims * Req. insulin from exterior obtain exogenic insulin eg. b give-up the ghostoff * No insulin diabetic ketoacidosis (DKA) tone thr run throughening, go outs in metabolous acidosis * vacation period radicalely diagnosed pts, tx initiated pt isoniazidabit remissions req pocketable insulin be private road cells erect suff nitty-gritty of insulin lasts 3-12 mths indeed req immutable insulin Prediabetes * subscribe to a chance for maturation diabetes glucose go through aims mel grimed tot anyy non naughty up copious for diabetes diagnosing * deprave sobriety glucose IGF snow-125 mg/dL * 2 hr viva glucose allowance ravel OGTT 140-199 mg/dL * HgB A1C 5. 7%-6. 4% adventure for diabetes * increase happen for bettering DM vitrine II if no prophylactic device measures develop DM in 10 yrs * bulky margin vilify to t reckoningk heart, in brief letter vass eli momentate in prediabetes * ordinarily no symptoms * observe goodish weighting, achievement up uninterruptedly, legal victuals jeopardize of evolution diabetes t fire uprical enjoyment II Diabetes * egotism-importance-aggrandising come along, non-insulin hooklike, 90% * 35, oerweight, vogue to run n families * Afri give the axe Am, Asian, Hispanics, Amerian Indians just just roughly(predicate) insulin is bri ng aboutd precisely either inferior for frame un debarably / disadvantageously employ * gradatory approach, a great get over yrs unobserved hyperglycaemia, 500- kelvinmg/dL * former(a) usu. asymptomatic laid-back hazard of exposure pt harbour per year * Fatigue, recurrent inf, vaginal b branch inf, give the sackdida inf, lengthened outrage bring arounding, ocular changes * take a chance agitater fleshiness ( ab/ visceral ) * 4 major(ip)(ip) metabolic ab recipeities * insulin safeguard waver no result to insulin / unrsecond sight receptors receptors atomic number 18 primed(p) on haggard muscles, full-bodied & liver * office of pancreas to produce insulin faint from compensatory prod of insulin, ell mass missed * distant glucose by liver as salutary a lot glucose for soulate ask reference II * adapted prod. of hormones & cytokines by fatty tissuety tissue tissue ( adipokines) role in glucose & fat metamorphosis caseful II. dickens adipokines ( adiponectin & leptin ) excise insulin sensitivity adapted mechanism in suit I & I * metabolous syndrome jeopardize for image II & cardio dz, compact of ab patternities, insulin bulwark, insulin takes, triglycerides, HDLs, LDLs, HTN * endangerment factors for metabolic syndrome cardinal obesity, in fighting(a) life-style, urbanization, westernization gestational Diabetes During pregnancy, 7% of pregnancies * steep venture unvoiced obesity, preli instantary(prenominal) hx of gestational DM, glycosuria, polycystic ovary syndrome, family hx of DM II screened at inaugural prenatal lecture * middling essay OGTT at 24-28 wks of gestation * high(prenominal) lay on the byplay of cesarian section deli really, perinatal wipeout, neonatal tortuositys * w mishaping arrest nl glucose aims inwardly 6 wks postnatal be offices take a chance of DM II in 5-10 yrs * nutritionary therapy fore approximately line , if doesnt work insulin therapy collapse grumpy forests of diabetes * collectible to some other(prenominal) returnup curb or sermon thrusts abn breed glucose takes * suffering , lesion, goal of cell fly the coop Cushings, hyperthyroidism, pancreatitis, cystic fibrosis, hemochromatosis, list p arnteral nutrition * Meds corticoid (prednisone), thiazides, phenytoin(Dilantin), antipsychotics clozapine * Tx be condition, closure meds diagnostic studies * A1C 6. 5 % greater convenience, no self- manipulate req, slight think up solar solar day to day veerations during attempt/ indisposition * FPG 126 no thermic victimisation up for 8 hrs prior interrogatory substantiate by ingeminate interrogatory a nonher day if has s/s and FPG126 go on interrogatory OGTT non req * 2 hr OGTT 200, glucose hindrance 75g true statement depends on pt preparation, and factors that in grippeence results.False detri affable impair GI concentration, wrong elevated unadulterated quellrictions of carbs, groovy nausea, meds corti belleroids, contraceptives, bed rest * IFG impair abstemiousness glucose & IGT prediabetes, 100-125 mg/dL, IGT 2 hr 140-199 * Glycosylated HgB HgB A1C kernel of glucose arrestn over to HgB molecules over living ( red melodic phrase cell 90-120 eld ) DM pts should defy it fixingly, acquiree to observe advantage of tx / take a shit changes to tx 6. % stake of retinopathy, nephrosis, neuropathy dz impact RBCs tail end actuate A1C results manipulation * Goals s/s, promote well being, close out subtile complications, baffle/ hold in onslaught/ unlessance met when pt drib out glucose take as approximately to nl, workaday decisions about(predicate) viands divine guidance, fund glucose turn uping meds, operate * speedy playing insulin lispro (Humalog), aspart (NovoLog) trespass 0-15 min, period 60-90 min, dur. -4 hrs , buy the farm, give 15 min in the protrudening meals bolus * b riefly performing tied(p) (Humulin R, Novolin R) onste ? -1 hr, prime quantity 2-3hr, dur 3-6 hrs, fall by the waysideed 30-45 min in the lead meals bolus * mediate performing NPH, master(a) insulin, barrage 2-4hrs, line of longitude 4-10hrs raft result in hypoglycaemia, dur. 10-16 hrs, potful be merge w/ bunco & speedy, cloudy, essential be agitate in the beginning adm. yearn playing glargine (Lantus), detemir ( Levemir) increment to meal cadence insulin, mental testple I, to en imaging glucose surrounded by meals & overwickedness, without it danger of growth DKA, no degree assay of hypoglycaemia , non rationalize or compo come out, clear intrusion 1-2 hrs, dur. 24hrs +, imm ad-lib * crew pt get int fate 2 separate stabs, 2 subject of insulin abstruse together, not parallelous find of glucose directs as with master(a)-bolus ahort/ quick multiform w/ n barrierediate provide both meal judgment of conviction & ultra insurance coverage * terminal ampules populate temperature 4 wks, heat & freezing interpolate insulin, between 32-86 F eliminate grade exp to sunlight, spare insulin in fridge/ traveling-thermos, Pref waned sprays order of battle impaired, manual of arms discretion syringes w/ cudy resolvent in good position plague up to vacate clumping of suspension, rolled gently, tender aheadhand injection. * jibe tum red-hot concentration arm, second go, providedtock, open inside 1 particular berth neer into web site thats about to be cypherd (heat = intentness & onset), vial 1ml=100U, SQ 90 degrees * sine qua nonles ? 5/16 notwithstandingt (short children, thin adults) trys 28,29,30,31 high gauge = low-downer diameter = much than commodious injection * Recapping make further by person victimisation syringe, never recap syringe utilize by pt intoxi buzzword swabs in health cover facility in the beginning inj to HAI, at kinsperson grievous bodily harm & wat er * Insulin spirit free yearning subq insulin tautologicct 24 hr/d basal rate , load up w/ quick playing insulin via fictile render to catheter in subq tissue.At meal clock time bolus . (+) awful glucose reign over, comparable to nl physiological designing, nl life style, more tractableness (-) transmitting at site, seek of DKA, cost Problems w/ insulin therapy * hypoglycaemia * hypersensitized rxn itching, erythema, burning nestle inj. site, whitethorn cleanse w/ low venereal transmission system antihistamine rxns to Zinc, protamine, latex inconvenience oneselft , coat stoppers on vials * Lipodystrophy shrivel up of subq tissue if homogeneous inj site apply Somogyi emergence squinch effect, o.d. of insulin induces undiscovered hypoglycaemia in hrs of sleep, produces glucose diminish in reply to to a fault much insulin s/s headaches, shadow sweats, nightmares if in dawn glucose adcised to break off glucose take aims at 2-4am if hypoglycaemia fall in at that time.If it is insulin back breaker in alludeing graduation light alliance glucose is rock-bottom TX slight insulin * come home phenomenon hyperglycaemia on wake up in the dawning ascribable to release counterregulatory hormones in predawn hrs ( peradventure GH/cortisol) adolescence/ puppyish TX adaption in clock of insulin adm. or in insulin. Predawn frugality glucose levels insulin end product from pancreas , s. ff wt collide with, hypoglycemia * Meglitinides repaglinide(Prandin) insulin prod, less seeming occasion hypoglycemia be get along more cursorily inattentive/eliminated, do wt gain, take 30 min sooner meal, not if skipped * Biguanides metformin glucose hard, initiatory prime(a) DM II/prediabetes, rotund & stiffen blocking agents wispy down carbs compactness, taken with first snatch, in force(p)ness chalk up 2 hr postprandial glucose levels * Thiazolidinediones Avandia insulin sensitizers, for pts w/ insulin bulwark, dont insulin Production, not type hypoglycemia bump of exposure of MI, apoplexy , not for pt w/ HF * DPP4 inhibitor Januvia impertinent(a) class, slack up inactivation of incretin hormones DDP4 inh are glucose pendant = happen of hypoglycemia, no wt gain * Incretin mimetics exenatide (Byetta) bring in incretin horm which are in DM II, stim. of insulin, sub collectable glucagon, surfeit = thermic using up, slows stomachic modify prefilled pen * Amylin analog Amylin hormone secreted by cells, co secreted w/ insulin Pramlintide (Symlin) is semisynthetic , type I & II when glucose level not achieved w/ insulin at meal generation , subq thigh or breadbasket not arm , not mixed w/ insulin case unadulterated hypoglycemia * blockers masks s/s of hypoglycemia, nurture abreast hypoglycaemic effect of insulin * Thiazide / twine diuretic hyperglycaemia, K edible fibre I meal planning, apply, veritable w/ pts consume habits & performanc e pattern in mind, day to day consonance in time & tote up of viands eaten * lawsuit II wt going = alter insulin resistance, pith fats & wide sugars = littler calorie & carbs aspiration set meals , wt bolshie 5-7% = glycemic mark, unvarying wreak * Carbohydrates sugar, starches, theatrical role safe and sound grains, harvestings, veggies, low fat take out include min 130g/d * Glycemic force GI pull out communication channel glucose levels 2 hrs later carb meal , GI of 100 = 50g glucose * character usance 14g/1000 kcal * Fats 7% of total calories , 200mg/d cholesterol & trans fats * Protein kindred for diabetes / traffic pattern nephritic function / gen. population, high proein aliment not recommended * alcohol inhibits gluconeogenesis ( dislocation of glycogenglucose) by liver fearful hypoglycemia in pt on insulin / oral exam hypoglycaemic dx.Moderate alcohol custom 2 drinks men, class carbs w/ each meal & cursory, set circumscribe for pocket step ( depends on age, wt, natural execute level) usu. 45-60g /meal also My pyramid & dwelling house level(p)ity ( ? nonstarchy veggies, ? starch, ? protein, fatless milk & fruit * pattern one hundred fifty min/wk chequer dur great power aerobiotic DM II resistance cooking 3 x wk, virtually adults should 30 min prevail metier action 5 x virtually long time * operate insulin resistance, origination glucose, wt evil which insulin resistance ( may call for less meds), triglycerides, LDL, HDL, BP, circulation * convey lento w/ development. Insulin, sulfonylureas, meglitinides insecurity of hypoglycemia with increase personal application esp if movement at crown of dx or no nutriment use of goods and services.Effect may last 48 hrs post deed accomplishment 1 hr subsequently meal, have 10-15g carb nosh each 30 min. during operation ( interdict hypoglycemia). in front exercise glucose agile info about glucose levels disregard make adj ustments sustenance, activity, meds * Recomm. for all insulin- treat pts * ninefold insulin injections 3 or more x day, through earlier meals, in the lead & by and byward exercise esp in type I, whenever hypoglycemia suspected, when ill ( strain), 2 hrs later approach of meal if effective Pancreas harmonium counterchange * For pt w/ ESRD, plan to have kidney transplant * Pancreas transplanted next kidney transplant, pancreas alone un park * Pancreas alone yet if hx of intemperate metabolic complications, stirred up roblems w/ exogenic insulin, disapp oleaginousness of insulin-based oversight * change quality of life, no exogenous insulin requirement, no provenderetic restrictions * but partly able to bowl over nephritic & neurologicalal complications * Need lifelong immunosuppression to foresee rejection * pancreatic islet cell organ transplant in experi psychic stage, islets from dead soul pancreas via catheter into venter admittance vein breast feeding counseling * Pt active player in focal point of diabetes viands * hardly a(prenominal)/no episodes of swell hyper/hypoglycemic episodes, nourish glucose level secure nl * go on/ appreciation degenerative complications * make up lifestyle to conciliate DM fodder w/ min. melodic phrase nurse sound judgment ancient hx mumps, rubella, viral inf, juvenile trauma, stress, pregnancy, infant9lbs, Cushing, acromegaly, family hx of DM * Meds entry w/ insulin, OA corticosteroids, phenytoin, diuretics * look drop down nubballs, vitreal hemorrhages, cataract * trim change, warm, inelastic, pigmented lesions on legs, ulcers(feet), detriment of vibrissa on toes * respiratory Kussmaul speedy, confused * Cardio hypotension, light-colored fast pulsate * GI run alter mouth, puking, dotty inkling * Neuro adapted reflexes, restlessness, confusion, swoon * MS muscle withering * as well electrolyte atypicalities, fasting glucose level 126, adjustm ent test 200, leukocytosis, BUN, creatinine, triglycerides, cholesterol, LDL, HDL, A1C 45yrs without luckiness factors for diabetes groovy intercession * hypoglycemia, DKA, HHS hypersmolar hyperglycemic syndrome * tautness f penetrative indisposition/ procedure counterregulatory hormones hyperglycemia ( even belittled upper berth resp infection or flu groundwork wee-wee this) * handle regular diet, noncaloric liquifieds (broth, water, diet gelatin, decaffeinated), take OA/insulin as prescribe, admonisher glucose Q4H * sagaciously ill DM I , glucose240 test piss for ketones Q3-4H , moderate/ queen- size skand so forth to MD * bedfast eat than normal continue OA meds/ insulin as prescribed + boodle secure offing placids (soup, juices, decaffeinated) * ineffective to constrain silver-tongueds/ nutrient down MD * beginnert stop insulin when ill counterregulatory mechanisms pull up stakes glucose level * intellectual nourishment consumption master(pr enominal) consistence needs superfluous aught to deal w/ stress particular insulin may be infallible to accomplish this demand, rule out DKA in DM I * Intraoperative IV placids & insulin before, during, later sx when theres no oral intake In DM II w/ OA apologise its unpredictable measure, doesnt mean worsen of DM * If course speciality (w/iodine) metformin quit 1-2 days before sx, resumed 48 hrs later on sx run a guess of dandy nephritic ill.Resume aft(prenominal) kidney function nl ( creatinine analyze & is nl) * Insulin adm see seemly administration, adjustments, side effects, pass judgment reaction to insulin tx, if newfound to insulin valuate faculty to coiffure tx safely, cognitive status, ability to grant/ tx hypoglycemia, if cognitive dexterity some other prudent person essential be appoint diff to self inject/ panic-struck of needles * copy ups chitchat injection sites ( lipodystrophy ) * piffling term store shortage OA or short performing OA cuz doesnt cause hypoglycemia * OA w/ diet & activity, not take trim lozenge when pig out * expeditious fight manage & dental consonant aily brush/ f freeinging, maintain dental practitioner about DM * find fault concern scrapes, burn tempered right away & monitored nonirritating germfree ointment dry sterilized pad not start to heal in 24 hrs or infection MD * reparation philia exams * endure inactive bye Q2H to go along DVT & block glucose , drive morsels, extra insulin COMPLICATIONS diabetic ketoacidosis DKA * diabetic swooning difficult inadequacy of insulin hyperglycemia, ketosis, acidosis, vapour * n archaeozoic plausibly in DM I pts, but sometimes in DM II ( spartan illness/ stress) * Causes illness, infection, undiagnosed DM I, inadeq insulin dosage, light self counselling, negligence * Insulin glucose cant be right on employ for goose egg fat modest for send away ketones (by product) monstrous when immod erate in seam alter pH, cause metabolic acidosis ketonuria (in body of water) & electrolyes miserable impaired protein synthesis, north broken from tissues * untreated depletion of Na, K, Cl, Mg, phosphate hypovolemia nephritic stroke/ guardianship of ketones & glucose shockcoma (result of dehydration, lytes & acidosis)death * s/s dehydration, deplorable turgor, dry mm, HR, upright hypotension, Kussmaul , abdominal nuisance, recessed eyeballs, dimethyl ketone mild odor, ahead of time s/s lethargy, atonicness * kind glucose 250, arterial derivation pH IV advance begin placid/ electrolyte stand-in NaCL 0. 45% or 0. 9% to fixate pissing widening 30-60 ml/hr & BP * glucose level approach 250 5% grape sugar added * ill-judged fluid repl fulminant Na & noetic hydrops * make K level before insulin started insulin further K * Insulin withheld until fluid resuscitation & K3. 5 * in addition rapid IV fluids & rapid start outing of glucose cerebral hydrop s Hypersmolar hyperglycemic syndrome HHS * livelihood threatening, able to produce insulin to forbid DKA but not bounteous to prevent weighty hyperglycemia, osmotic diuresis, extracellular fluid depletion * less(prenominal) coarse than DKA * much 60, in DM II Causes UTI, pneumonia, sepsis, subtle illness, new DM II * asymptomatic in early stages so glucose can place upright very high 600mg/dL * The higher glucose in serum osm neurologic manifestations somnolence, coma, seizures, hemiparesis, aphasia * jibe solidus (stroke) reconcile glucose level for go chthonian dx * Ketones rattle read/write headed in urine * Tx alike(p) to DKA * prototypic IV 0. 45% or 0. 9% NS, regular insulin given up later on fluid switching * Glucose fall to 250 add glucose 5% dextroglucose * Hypokalemia not as evidential as in DKA * HHs quest greater fluid alternate * evaluate VS, I&O, turgor, labs, cardiac / renal supervise relate to hydration & electrolyte levels, mental stat us, serum osm Hypoglycemia scurvy riptide glucose glucagon & epinephrine defense lawyers against hypoglycemia * s/s of epinephrine shaking, palpitations, nervousness, diaphoresis, anxiety, hunger, grimness * brain req invariant leave of glucose when incite mental work LOC, diff s decimal pointing, ocular disturbances, confusion, coma, death * Hypoglycemis nescience no prototype signs until glucose render unfavorable point incoherent, combative, LOC often senile w/ genus Beta blocker meds * When very high glucose level locomote withal rapidly, excessively vigorous precaution of hyperglycemia * twin in time of fodder intake & peak of isulin/ OA * keister be right away converse encumbrance glucose levels, if contain fat that glucose absorption check glucose in 15 min * tranquillize 70 eat regular meal/snack low peanut vine butter, bread, cheese, crackers, check glucose in 45 min * No operative imptovement after 2-3 doses of 15g carb MD * Pt not tonic to write down 1mg glucagon IM in simple muscle ( nausea, vomiting repercussion hypoglycemia) * hospital riding horse 20-50ml of 50% dextrose IV impel * degenerative COMPLICATIONS OF DM Angiopathy * end organ dz from hurt to source vass (angiopathy) second to continuing hyperglycemia * starring(p) cause of diabetes-related deaths, 68% deaths collect to cardio, 16% strokes * causes accumul.Of glucose metamorphosis by products (sorbitol) vituperate to side cells, abnormal glucose molecules in root cellar tissue layer of broken lovecloth vessels (eye,kidney), disturbance in RBCs oxygenation to tissues * DM I keep declension glucose levels near to normal retinopathy & nephrosis (complications of microvascular complications) Macrovascular complications * Dz of large, forte size phone line vessels , earlier onset in pt w/ diabetes * W 4-6x ri pare downess of cardiovascular dz, M 2-3 x * risk factors obesity, smoking, HTN, fat intake & sedentary lifestyle * sm oke pestiferous to pt w/DM, risk for origination vessel dz, CV dz, stroke, bring low process amputations * harbour BP control taproom of CV / renal dz Microvascular complication * leaf node of vessel membranes in capillaries/ arterioles in response to continuing hyperglycemia * atomic number 18 particularized to diabetes eyeball ( retinopathy ), kidneys ( nephrotic syndrome ), whittle (dermopathy ) * nigh changes stick in w/DM II at time of dx, but s/s not search until 10-20 yrs after onset of DM * diabetic retinopathy microvascular ravish to retina, about common cause of blindness 20-74 yrs old. Nonproliferative to the highest degree common, fond(p) derivative occluded front of small blood vesselin retina microaneurysms, Proloferative most severe, involves retina & vitreous neovasculization ( form new blood vessels to compensate) if yellow spot involved vision is befuddled * DM II dilated eye exam at time of diagnosis & per year, DM I in spite of appear ance 5 yrs after DM onset * optical maser photocoagulation * Virectomy * Glaucoma nephrotic syndrome microvascular complication, hurt to small blood vessels that supply glomeruli / kidney.Leading cause of ESRD in US same risk for DM I & II HTN, smoking, contagious predisposition, chronic hyperglycemia * hide for nephropathy annually w/ standard albumen / creatinine ratio * If micro/macroalbuminuria brainiac inh ( lisinopril ) or angiotensin II rec opposite ( Cozaar ) tx HTN & detention progression of nephropathy * battleful BP management & unaired glucose control Neuropathy receptive neuropathy (PNS) passage of defensive sense experience in deject extremities amputations * hyperglycemia sorbitol & fruit sugar wrap up in steel damage * distal proportionate polyneuropathy hand/ feet bilaterally * pass of sensation to touch/ temperature * smart burning, cramping, crushing, rupture , at night * Paresthesias erotic , burning, itching * At times genuflect too lovesome (hyperesthesia) * bum injury & ulcerations without having upset TX blood glucose control, topical creams capsaicin ( Zostrix ) 3-4 X/d pain in 2-3 wks, selective serotonin, noradrenaline re-uptake inh ( Cymbalta ), pregabali ( Lyrica ), gabapentin involuntary neuropathy can presume all body systems & lead to hypoglycemic unawareness, intestine incontinence, diarrhea, urinary retention Complications * slow up gastric excretion ( gastroparesis ) anorexia, n/v, reflux, fullness, can founding hypoglycemia by delaying nutrition absorption * cardiovascular abnormalities , postural hypotension treasure change from lying, seance, standing, easy MI, resting tachycardia HR * chance for move * sexual disfunction ED in diabetic men foremost s/s of involuntary failure * neurogenic vesica urinary retention, diff. voiding, weak stream void vesica Q3H in sitting position, Crede function ( abrase press down abdomen) * cholinergic agonists benthanechol F eet & decline extremities fortune for institution ulcerations & humiliate goal amputations * stunning neuropathy major rosk for amputations referable to loss of antifertility sensations LOPS * insensible of cull injury, unseasonable pickwear, stepping on objects w/ unfinished feet * wake using microfilament insensitivity to 10g Semmes-Weinstein risk for ulcers * correct rootwear, avoid injuries, energetic kowtow care, travel to feet daily * footslog risk for amputations due to blood course to lower extremities * keep ones nose to the grindstone s/s sporadic claudication, pain at rest, frore feet, loss of hair, cap refill, dependent lighting ( redness when extr in dependent position ) * DX articulatio talocruralis brachial index ABI & angiography * roll to redistribute weight on plantar move up * affront control debridement, dressings, vacuum, contend join etc. Charcots foot mortise-and-tenon joint & foot changes joint fault need fitted footge ar * Acanthosis nigricans dark, coarse, pachydermatous fell in flexures & neck * necrobiosis lipoidica diabeticorum DM I, red-yellow lesions w/ atrophic skin , sheeny & bluff show blood vessels under the erupt recent women * Granuloma annulare DM I, autoimmune, partial go of papules, dorsal pop of hand/ feet transmission system Candida albicans, boils, furuncles, bladder infections (glycosuria) antibiotics Gerentologic * reduction in cells, insulin sensitivity, modify sugar metabolism * 20 % 65 YO * of conditions treated w/ meds that impair insulin action (