In this video, I will discuss chronic complications of diabetes mellitus. There are three main areas of long-term complications in diabetes. You have macrovascular, so talking about coronary artery disease, cerebrovascular disease, peripheral vascular disease, general atherosclerotic changes in larger vessels. Then you also have microvascular, which is what we're really going to talk about more so in MedSurge1. But microvascular, those itty bitty little capillaries in your retina and your kidneys and your toes and your fingers, those are the little tiny fragile blood vessels.
They're going to be affected first because of a caustic high level of hyperosmolar blood sugar. Then you're also going to have neuropathic long-term complications because of the damage to the blood vessels. Because the blood vessels are damaged.
then the nerves don't get the oxygen and the nutrients they need, and they start to become irritated and eventually die. And that results in peripheral neuropathy. So losing of the feeling in the fingers and toes that progressively moves inward, it moves medially. You may even have autonomic neuropathies.
So people may have problems with balance and proprioception and digestion and all these things. They may also have hypoglycemic unawareness because again, when you become hypoglycemic, that tells your, or your sympathetic nervous system tells you, hey, we've got a problem. But if your sympathetic nervous system is damaged because of neuropathy, you may not sense that you are hypoglycemic and you're going to go from seemingly fine, fine, fine to a coma. Of course, other areas of neuropathy, just anywhere in the body. So again, like retinopathy, neuropathy, those kinds of things.
And then also sexual dysfunction. They may also have issues with dementia. So there's anything.
that involves innervation, which is basically everything your body can be eventually affected by diabetes because these nerves just can't get the nutrients and the oxygen they need because of blood vessel damage. So just telling you a little bit more about what you're going to cover in MedSearch 2 with Ms. Shepard. So coronary artery disease, CAD, cerebrovascular disease, CVD, peripheral vascular disease, PVD.
You're going to talk a lot more about cardiovascular and med-surg too, because this high level of blood sugar causes these blood vessels to thicken and sclerosis become occluded by plaque. Because as we know, when those blood vessels are damaged, they have a lot of cholesterol deposition, and it ultimately causes a blocking or a restriction of blood flow. So the microvascular complications we're really going to focus on, two of the types of neuropathy that we'll talk about. include diabetic retinopathy, so vision changes, and then nephropathy in relation to blood vessel damage in the kidneys. Now you also have peripheral neuropathy too from microvascular damage because the blood sugar just causes that capillary basement membrane thickening and damage because of that persistent hyperglycemia.
Essentially your blood vessels become scarred. So a little bit more on microvascular. So diabetic retinopathy. That is basically when the retina in your eye, which is essentially an extension of your optic nerve, becomes damaged because of poor blood flow because of high blood sugar.
So how do we help these patients manage this? Well, of course, anytime you have a patient who's a diabetic, they need to be getting regular, I cannot say this word, ophthalmologic, I've never been able to say it, examinations. So that if they have any damage, we can catch it early, maybe take a look at those. blood sugar medications, maybe just diet, exercise, something to prevent further damage.
And of course, blood glucose control, because it's when their blood glucose is out of control, they have these damage. Self-management of eye care regimens. So making sure that they have any other problem like glaucoma or any kind of other just general ocular care that they need to, macular degeneration, those kinds of things, so they can tell what's causing the damage. Is it because of uncontrolled blood sugar or some other problem?
High blood pressure causes blood vessel damage, so that could also just further contribute to retinal damage. Stopping smoking. Guys, smoking is a risk factor for everything.
If you smoke, stop. I know it's difficult to do, but there are just so many opportunities for you and patients to stop smoking. I've seen many people in my family try to stop smoking, successfully stop smoking, and also smoke themselves to death.
So now, you know, being a nurse and understanding how bad it is for you, oh my goodness. Can you tell this is a soapbox? But just cessation of smoking is so important because smoking causes vasoconstriction, which further cuts off blood flow to just everywhere in your body.
And then of course, for advanced cases, they might have a photo coagulation treatment. So it basically goes in and destroys the problem vessels to hopefully promote collateral creation of other blood vessels. Another microvascular concern in long-term complications of diabetes is nephropathy because that hyperglycemia again damages those blood vessels. It causes blood proteins to leak into the urine.
It might also, hyperglycemia might contribute to hypertension, which then causes all this extra pressure in the blood vessels of the kidneys. And just those two things together, or even independent, just lead to damage of that little glomerulus in your nephron, which is just a little knot of vessels. It just doesn't work anymore. It becomes destroyed and you end up with nephropathy and renal damage. So how do we help these patients manage this?
Well, of course, that blood sugar control. It is just the cornerstone. of diabetic management. So making sure that they do everything they can to maintain and achieve those normal blood glucose levels through exercise, diet, frequent monitoring, taking their meds. Also controlling hypertension.
Like I said, these two are related. Prevention or vigorous treatment of any kind of a UTI so it doesn't just aggravate the damage that's already there or just contribute to damage caused by high blood sugar. Avoid nephrotoxic medications.
If they can avoid contrast dye, that IV push contrast dye that a patient might receive for some kind of imaging, it just doesn't play well with the kidneys. So if you already have any kind of renal damage or you're at high risk for it, just avoid those meds if at all possible to avoid any further damage. Adjust medications as kidney function changes because we just, as we know, kidneys excrete one of the organs that help us excrete medications from our body. So we may have to adjust as renal function declines or maybe even improves after an acute kidney injury.
Have a low sodium and a low protein diet if we have renal damage because again that sodium can cause retention of fluids, make the kidneys work harder. And then low protein if we already have renal damage because a high protein diet can just be really hard on the kidneys. They may have to have continuous ambulatory peritoneal dialysis, which is a means for dialysis that does not require being hooked up to one of those huge hemodialysis machines.
They can actually walk around with a little kit that helps them with dialysis through their peritoneal space. And then of course, helping them manage any end stage kidney disease, which may include dialysis. So something, you know, hemodialysis or peritoneal that actually cleans out their blood for them and or transplantation if they're a candidate for that. So this is just a great picture of what your kidneys look like when they're healthy.
So over here on the left, nice healthy kidney. You've got this glomerulus, this little knot of vessels. You've got collecting tubules. Everything looks great. And here you have a diseased kidney.
It just kind of shriveled. Everything, that glomerulus is damaged. It's really diffuse. It's just not as clear.
You can't really see what's going on in there because it's damaged. So just taking you back to anatomy and physiology, here's a nice drawing of that glomerulus. or the nephron unit, and then this little knot of vessels right here, this is your actual glomerulus, where you have nutrients and fluid that through filtration, that pressure is pushed into the nephron, and then it's excreted through all this very convoluted tubules that also help regulate fluid and electrolyte balance.
So neuropathic, this is more talking about just general nervous system damage. This is due to vascular... and or metabolic mechanisms. So vascular damage, maybe because they've had decay too many times and all that high amount of acid can cause that vessel damage. So basically the nerves just don't get perfused.
The nerves begin to demyelinate. So that entire nerve conduction becomes disrupted because remember that that myelination of the nerves, your nerves are essentially wrapped in electrical tape. They really have insulation around them.
They have like a cell. I want to say it's a Schwann cell. I'd have to look that up. Honestly, it's been a minute, but I think it's a Schwann cell that wraps around the neuron that insulates that electrical activity to make sure that that impulse gets to the right spot. So if your nerves don't get perfused, they demyelinate, they no longer have the control of the conduction and it causes all kinds of that nerve pain.
And nerve pain is terrible. I've actually had nerve pain and taken care of quite a few patients that have had it. It's burning. It's awful.
It's, it's all encompassing. It's really terrible. because it just feels like your fingers, because I had it in my fingers from a neck injury, they feel like they're on fire and they just, there's nothing you can do to relieve it.
It's very aggravating. So you can have both peripheral nervous damage, so that losing in the fingers or the toes. And again, like I said before, autonomic.
So you may have poor regulation of blood pressure. That's something I've seen where a patient had to be on, was it mitadrine, I think, because they had orthostatic blood pressures because their nervous system was damaged from diabetes. they could no longer regulate their blood pressure from sitting to standing. It was really sad. So peripheral neuropathic, again, it's just affects those distal portions of the nerve.
For some reason, it starts in the feet. About 50% of patients who have nerve damage are asymptomatic. So there's damage.
They just haven't sensed it yet. So by the time you actually start feeling symptoms, you have really significant damage to those nerves. And as we know, nerves don't heal well or at all.
So it's either a very long road to recovery or it's permanent. So you can have both initial symptoms, which is paresthesias. We talked about that with unit one. So it's just weird feelings, prickling, tingling, burning.
It's awful. And then late stage symptoms is just numbness. That nerve is just dead.
So this can cause a decrease in awareness of posture because your nervous system helps you see where you are in space or feel where you are in space called proprioception. Movement. You can't tell your muscles what to do well if your nerves aren't working. You also might have that decreased sensation of touch. So If you've ever seen a patient with advanced peripheral neuropathy in their feet, they shuffle because they just can't feel their feet.
And so they don't really walk with a normal gait because they just can't feel where they are in space. Their feet can't feel the floor. So think about walking on a foot that you've been sitting on while studying or something like that. Like you woke up with your foot's asleep and then trying to walk on that. It's really awkward.
So of course, decreased sensations of pain and temperature because your nerves sense pain, they sense temperature. Um, so they also might have a deformity of the foot too, because, um, over time, those muscles, those tendons, they start to break down because they just don't have that blood flow and that activity caused by nervous stimulation. So the foot starts to become deformed.
So how do we help these patients manage or prevent this issue? Insulin therapy, um, as needed or anti-diabetic medications. But the key thing is controlling that blood glucose.
And ideally with just a better understanding of how their lifestyle contributes to it if they're type 2. And then for both type 1 and type 2, checking that blood glucose as frequently as they can just to help try to keep that glucose level as tight as possible. And then, of course, if they have peripheral pain, so that tingling, that paresthesia, any kind of like gabapentin, I think sometimes Lyrica is prescribed, that can help with that pain because nerve pain is terrible. So this is just a great graphic I wanted to share with you that gives you a nice picture for those of us who are very visual, what happens when you have diabetic nephrop or neuropathy. So these blood vessels start to die.
And because the blood vessels are diseased, that myelination, those little cells that wrap around the nerves start to shrivel. And so then you have all of this uncontrolled nervous stimulation and nerve death. So neuropathic, talking a bit deeper now into autonomic.
These patients may have cardiac problems. So like I said, orthostatic hypotension. These patients are the ones that they may have a heart attack, but they just feel a little bit nauseated because they can't, their nervous system can't feel the pain of ischemic pain of a heart attack.
It doesn't go down their arm like it, you know, typically showed her up their jaw or any of these classic symptoms of an MI because their nervous system is so damaged. They don't feel that anymore. They just might feel nauseated. GI, they might have delayed gastric emptying because your GI tract has its own, it's an enteric nervous system. And of course that can be damaged too.
Early satiety, bloating, it's just basically gastric slowdown, which causes nausea, vomiting, and it's just called a diabetic constipation and or diarrhea, depending upon what's going on. So a lot of GI symptomatology. And then renal, of course, because of renal damage, they have urinary retention because part of...
You know, what allows you to urinate is that muscular innervation of what the detrusor muscle that allows you to actually void. And then you may get a UTI because they just can't appropriately empty the bladder anymore because that muscle can't be innervated appropriately. So these four patients end up with a lot of problems.
So long-term complications of diabetes, I really want to focus a little bit on the increased risk of foot problems and infection. So if you've never seen a diabetic foot ulcer, here you go. Here's some great pictures.
Um, I've seen some pretty terrible ones. The one up at the top looks more like a dry, a dry gangrene. Um, like those toes, unfortunately they could just potentially snap off because that's all just dead tissue.
Uh, I've actually had a physical therapist tell me they were doing hydrotherapy on a diabetic patient and their toe literally just floated off their foot and started swirling the pool because it was dead. It was just dead tissue. So foot and leg problems. These are, so between 50 to 75% of all lower extremity amputations are performed on people with diabetes.
So in developed countries, in first world countries, the vast majority of amputations is not because of trauma. It's because of diabetes, because diabetes is just so prevalent in first world countries because we're sedentary, because we have a lot of processed foods. Yeah, we're just at really high risk for amputation.
So that sensory neuropathy, again, that leads to that loss of pain and pressure sensation. So they have to check their feet daily, not weekly, not monthly, every single day, because well, most people walk or they use their feet every single day. So if you step on something, if you stub your toe, if you get a blister with new shoes, you're going to notice it because you've been walking in those shoes all day.
And so you're going to look at your foot and care for it. But a diabetic may not know that. They may have a nasty blister.
I've seen, gosh, x-rays of patients with giant needles in their feet and nails because they had no idea it was there. They just couldn't feel it. And they didn't inspect every day.
They can't feel injuries. So they can't feel like a hot water bath. They can't sense temperature with their toes.
So they can, you know, fry their poor feet with heating pads. They can't walk barefoot on hot concrete because they can't sense the temperature. They also can't sense any kind of chemical changes.
Like let's say maybe you just have a reaction to some sort of a bath soap or you drop some sort of cleaning agent on your foot. If you've ever dropped a cleaning agent on your skin, it tends to cause irritation. Well, they can't feel that. Of course, trauma, a big one is injuring that skin around the toes while cutting the nails. That's why.
at least in acute care, you cannot touch their toenails. It has to be the podiatrist or someone who's specifically trained. Now, I know there are some places like nursing homes that allow for people to be trained to cut nails, but you have to really be trained well so that you don't cause an ingrown toenail, which can become infected, which can cause a diabetic patient to lose their foot or their leg below their knee.
Also just wearing ill-fitting shoes and socks. So they have to have very specific footwear and they have to sometimes take their shoes and socks off multiple times throughout the day just to allow their feet to air. So you don't get damage just from being enclosed in the shoe and being really, really moist. Then also that autonomic neuropathy leads to dryness of the skin and fissuring of the skin. That skin just does not, it can't repair itself as well as it could if it had a full blood supply.
So you also have motor neuropathy because the muscles aren't working anymore and they ultimately lead to a change in the shape of the foot. So this is called, I think I'm saying this right, Charcot foot. And you can see that their arch collapses.
And so look at how the bottom of this foot is shaped. I mean, this patient's going to be at really high risk for foot damage just because of the shape of that foot. So they're at super high risk for ulcerations and damage. They also have a peripheral vascular disease just because of poor um, tissue perfusion. So that puts their feet at even more risk for damage and infection.
And then of course they're immunocompromised. Their white cells can't communicate like they should because of all the blood sugar. So now they're going to get infected. So not only their foot changes, they can't feel, um, to prevent or take care of trauma.
They're not getting good blood flow, uh, and they can't fight off infection. So you put all that together and they're super high risk for amputation due to infection and trauma, uh, and wounds that just won't heal. So how are foot ulcers treated? Well, bed rest to a degree because we don't want people walking on them.
But as we'll talk about in unit three, bed rest causes a whole slew of other problems, pneumonia, DVTs, muscular atrophy. So that's got to be balanced with all those other things. Of course, antibiotics, wound debridement, actually getting that dead tissue out of there so that that foot can heal and that skin can grow back. And then of course, of course, of course, controlling those glucose levels.
which again, tend to increase when infections occur. So if you're hyperglycemic, if you've got diabetes, and now you have a nasty infection in your foot, well, your body is stressed. So your blood sugar is going to increase even more.
And so they've got to have even tighter control of their blood sugar. So again, sometimes these infections become so nasty and so deep. Sometimes they might even go into the bone and osteomyelitis is something we'll talk about in unit four.
And it goes all the way to where they just have to have the limb removed because it's just so infected and they just can't get ahead of that infection. to prevent things from their infection from going sepsis and killing the patient. It's just best to remove the necrotic dying and infected limb.