Long-Term Complications of

Diabetes Mellitus
Chronic complications of diabetes

 Categories of longterm diabetic

complications
 macrovascular disease
 microvascular disease

 Neuropathy

 Hypertension -major contributing factor

especially in macrovascular and
microvascular disease
Long-term complications of diabetes mellitus
Chronic hyperglycemia damage to cells &
tissues possibly by:

 1. Accumulation of damaging by-products of

glucose metabolism-sorbitol
 a. Associated with damage to nerve cells
 2. Formation of abnormal glucose
molecules in the basement membrane of
small blood vessels - eye and kidney
 3. Derangement in red blood cell function
leads to ↓in oxygenation to tissues
Macrovascular

 Macrovascular complications
 Diseases of the large and medium-size
blood vessels
 Occur with greater frequency and earlier
onset in people with diabetes
 Macrovascular diseases
 Cerebrovascular, coronary artery, and peripheral
vascular disease.
Macrovascular Changes

 Atherosclerotic changes
 Blood vessels thicken & become thickened
by plaque→adheres to vessel wall
 Eventual blockage of blood vessel

 Changes occur at an earlier age and more

often in the diabetic
Macroangiopathies
 Cerebrovascular Effects
 Glucose – stiffens the RBC’s, making platelet
aggregation easier
 Leads to TIA’s and causes CVA’s
 People with diabetes- 2x risk of
cerebrovascular disease
 Recovery from stroke impaired if blood
glucose ↑at time of event
Macroangiopathy

Coronary artery disease (CAD)

 MI- 2x as common in men & 3x as
common in women with diabetes
 ↑ likelihood of second MI
 Ischemic symptoms may be absent
 May be secondary to autonomic neuropathy
 Silent MI common in DM
 Macroangiopathy
Occlusive Peripheral Arterial Diseases

 Occurs 2-3x more frequently in diabetics

 Signs & symptoms
 Decreased pulses
 Intermittent claudication (pain in buttock,
thigh or calf when walking)
 Gangrene & amputation – result from
severe form of arterial occlusion
 Interventions for occlusive peripheral
arterial disease

 Good SMBG control- medication compliance

 Protect feet from heat and cold
 Foot care:
 Wash daily in warm water, dry well, inspect feet
daily (use mirror to √ bottoms)
 Keep skin soft; gently smooth corns & calluses
 Trim toenails straight- emery board to edges
 Wear closed toe well-fitting shoes & socks – avoid
any irritation of foot
 No smoking (causes vasospasm)
 Examine feet daily
 Reduction of risk factors for
Macroangiopathies

 Medical nutrition therapy & exercise

 Reduces obesity & hyperlipidemia
 Obesity increases insulin resistance

 BP control – lifestyle changes

 Tight Blood Sugar control

 ↓triglyceride concentrations
 ↓ complications

 No smoking
Microvascular Complications

 Result from thickening of the vessel

membranes in the capillaries and
arterioles from chronic hyperglycemia

 Areas most affected

 Eyes (retinopathy)
 Kidneys (nephropathy
Microvascular changes

 Present in some patients with type 2

diabetes at time of diagnosis

 Clinical manifestations usually do not

appear until 10 to 20 years after the
onset of diabetes
Diabetic Retinopathy

 Most common cause of new cases of

blindness in people ages 20 to 74 years
 Occurs in Type 1 & Type 2 diabetes
 Deterioration of small blood vessels that
nourish the retina

 Maintenance of blood glucose to near

normal in type 1 - decrease risk by 74%
Diabetic Retinopathy

 Stages:
 nonproliferative stage- results in
microaneruysms → capillary fluid leakage→
retinal edema
 proliferative-most severe form- retinal
capillaries become occluded
 New fragile capillaries form- hemorrhage easily
and cloud the vitreous→ loss of vision
 Scar tissue also forms→ retinal detachment

 Blurred vision secondary to macular edema

often occurs
Management of Retinopathy
 Annual eye exam- screen for retinopathy
 Laser photocoagulation
 Destroys ischemic areas of the retina that produce
growth factors that encourage neovascularization
 This prevents further visual loss - reduces the rate of

progression to blindness
 Done as outpatient- can return to normal ADL

 Control BS levels
 Control hypertension
 Cessation of smoking
Other eye problems in diabetes

 Glaucoma -results from occlusion of the

outflow channels secondary to
neovascularization
 This type of glaucoma is difficult to treat
and often results in blindness
 Cataracts develop at an earlier age and
progress more rapidly in people with
diabetes
Diabetic Nephropathy

 A microvascular complication
 Damage to small blood vessels that supply
the glomeruli of the kidney
 Leading cause of end-stage renal disease
(ESRD) in the United States
 Risk of nephropathy is about the same in
patients with either type 1 or type 2 diabetes
 Symptoms occur 10-20 yrs after diagnosis of
diabetes
Pathophysiology of nephropathy

 Consistent elevation of blood glucose

for a significant period of time
 Proteins leak into urine d/t stress on
filtration mechanism
 Pressure in the blood vessels in kidneys
increases
 Stimulates development of nephropathy
Management of Nephropathy

 Monitor urine for microalbuminuria, BUN,

creatinine annually
 Blood glucose control to prevent & delay
development of nephropathy
 Use of ace-inhibitor drugs – delay progression
of nephropathy
 Aggressive control of BP- to slow progression
of nephropathy
Other interventions for nephropathy

 Decrease protein intake if indicated

(renal diet)
 Low sodium diet
 Avoid nephrotoxic substances
 Dialysis or transplant
Diabetic Neuropathies

 Nerve damage due to metabolic

derangements from diabetes
 Demyelination of nerves from
hyperglycemia
 Most common types:
 sensory or peripheral neuropathy
 autonomic neuropathy
Peripheral Neuropathy

 May involve all extremities – usually lower

 Symmetrical and bilateral
 Sx:
 Burning pain (night)
 Paresthesia & unable to feel where feet are
 Decreased sensation of pain and temp - ↑ risks of
injury to feet
 Foot & hand deformities caused atrophy of small
muscles of the hands and feet
Neuropathy: neurotrophic ulceration
Management -Peripheral Neuropathy

 Control of blood glucose -only

treatment for diabetic neuropathy
 Medications:
 Analgesics, antidepressants, Neurontin
 Capsaicin- topical cream from chili peppers-
depletes the accumulation of pain-mediating
chemicals in the peripheral sensory neurons
 TENS units
Autonomic Neuropathies

 Can affect all body systems

 Three systems often involved
 Cardiac
 Gastrointestinal

 Renal
Autonomic - Cardiovascular

 Fixed tachycardia
 Orthostatic hypotension
 Change from a lying or sitting position
slowly to avoid fainting & injury
 Painless MI
Autonomic GI Tract Neuropathy

 Gastroparesis
 Delayed stomach emptying and decreased
peristalsis
 Anorexia, bloating,

 Can delay absorption of food

 ↑motility of GI tract
 Low fat diet
Autonomic – Urinary Tract Neuropathy

 Neurogenic bladder with urinary

retention
 Inner wall of bladder loses ability to
sense pressure
 Bladder empties incompletely
 Increases risk of UTI
Treatment of Urinary Tract Neuropathy

 Urecholine- cholinergic agonist

 Acts on nerves that innervate bladder
 Antibiotics for UTI
 Manual pressure q 2 hr – Crede’
 Learn self-catheterization
Reproductive System Neuropathy

 50% of males affected- erectile dysfunction

 May have retrograde ejaculation

 Fertility counseling if attempting conception

 ↓ libido & ↑ in vaginal infections in women

 Treatment:
 Meds, surgery
 Increased Susceptibility to Infections

 Related to high BS levels

 Impairs phagocytosis by neutrophils and
monocytes
 Loss of sensation (neuropathy) may
delay the detection of an infection
 Treatment of infections must be prompt
and vigorous
Implications with Infection & Diabetes

 Healing is slow
 Related to impaired vascular supply
 Not enough oxygen to tissue, nutrients,
antibodies d/t poor circulation
 Infections increase the need for insulin
 Often insulin is needed in the hospitalized
diabetic, even if they do not take it at home
Nursing Role

 Assess for complications in the diabetic

patient r/t the cardiac, vascular and
nervous systems

 Educate the patient and caregiver about

prevention and management r/t chronic
complications of diabetes
THANKS…..