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680
AClITE CARE HANDBOOK FOR PHYSICAL ll-IERAJlISTS
nos is. They can be classified as (1) microangiopathy (microvascular
disease), which causes retinopathy, nephropathy, and foot ischemia;
(2) macroangiopathy (macrovascular disease), which accelerates
widespread atherosclerosis; or (3) neuropathy.J2 Another complication from diabetes that is not directly linked to vascular damage is diabetic ketoacidosis (DKA).
Diabetic Ketoacidosis
The metabolic syndrome of diabetes mellitus gradually progresses
from mild to moderate glucose intolerance, to fasting hyperglycemia,
to ketosis, and, finally, to ketoacidosis. Most patients do not ptogress
ro the ketotic state bur have the potential to do so if proper treatment
is not administered.12
DKA is the end result of ineffective levels of circulating insulin,
which lead to elevated levels of ketone bodies in the tissues. This state
of an elevated level of ketone bodies is referred to as ketosis.
Decreased insulin levels lead to uncontrolled lipolysis (fat breakdown), which increases the levels of free fatty acids released from the liver and ultimately leads to an overproduction of ketone bodies.
Ketone bodies are acids, and if they are not buffered properly by
bases, a state of ketoacidosis occurs. Ketoacidosis almost always
results from uncontrolled diabetes mellitus; however, it may also
result from alcohol abuse.6.12.JJ
The following are signs and symptoms of DKA 12:
•
Polyuria, polydipsia, dehydration
•
Weakness and lethargy
•
Myalgia, hypotonia
•
Headache
•
Anorexia
•
Nausea, vomiting, abdominal pain, acute abdomen
•
Dyspnea, deep and sighing respirations (Kussmaul' respiration)
•
AcetOne-smelling ("fruity") breath
•
Hypothermia
•
Stupor (coma), fixed, dilated pupils
•
Uncoordinated movements
•
Hyporeflexia
ENDOCRINE SYSTEM
681
Management of DKA may consist of any of the following: insulin
administration, hydration, clcnrolyte (sodium, potassium, and
phosphorus) replacement, supplemental oxygen, and mechanical
venti lation. 6,29,33
Diabetic Dermopathy
Skin lesions in patients with diabetes, parriculary on their feet, are
common and multifactorial in nature. Lesions may result from any
combination of the foliowing,,·J2 .. o:
•
Loss of sensation from sensory neuropathy
•
Skin atrophy from microangiopathy
•
Decreased blood flow from macroangiopathy
•
Sensory and autonomic neuropathy, resulting in abnormal
blood distribution that may cause bone demineralization and
Charcot's joint (disruption of the mid foot)"
Proper foot care in diabetic individuals helps prevent complications, such as poor wound healing, which can progress to tissue necrosis and ultimately lead to amputation.'o Table 11-10 describes
patient information regarding foot care for patients with diabetes.
Refer to Chapter 7 for more details on diabetic ulcers.
Infection
Individuals with diabetes are at a higher risk for infection because of
(I) decreased sensation (vision and touch); (2) poor blood supply,
which leads to tissue hypoxia; (3) hyperglycemic states, which promote rapid proliferation of pathogens that enter the body; (4) decreased immune response from reduced circulation, which leaves white blood cells unable to get to the affected area; (5) impaired
white blood cell function, which leads to abnormal phagocytosis;
and (6) chemotaxis.'·,'2
Diabetic Neuropathy
The exact link between neural dysfunction and diabetes is unknown;
however, the vascular, metabolic, and immunologic changes that
occur with diabetes can promote destruction of myelin sheaths and
therefore interfere with normal nerve conduction.43
Neuropathies can be manifested as (1) focal mononeuropathy and
radiculopathy (disorder of single nerve or nerve root); (2) symmetric
sensorimotor neuropathy, associated with disabling pain and depression; or (3) auronomic neuropathy.
682 AClITE CARE HANDBOOK FOR PHYSICAL TI-fERAPISTS
Table 11-10. Foot Care for Patients with Diabetes
Don't
Do
Smoke.
Encourage the patient to have regular
Wash feet in cold or hot water. The
medical or podiatric examinations to
water temperature should be
determine integrity of his or her feet.
lukewarm (approximately 85-
lnspeer feet daily for abrasions, blis95°F).
ters, and curs. Use a mirror if sales
Use a heating pad, heating lamp, or
cannot be seen. If vision is poor,
hot water bottles to warm the
another person should check feet.
feet.
Wash feet daily with lukewarm water
Use razor blades or scissors to cur
and soap.
corns or calluses. Have a podia
Dry feet carefully, especially between
trist perform this procedure.
the roes.
Use over-the-counter medicacions
Apply hand cream or lanolin to feet
on corns or calluses.
(dry areas).
Cross legs when sitting.
Be careful not to leave cream between
Wear girdles or garters.
the toes.
Walk barefoot.
Wear clean socks or stockings daily.
Wear shoes without socks or
Cut nails straight across and file down
stockings.
edges with an emery board.
\'(Iear sandals with thongs between
Wear comfortable shoes that fit and
the roes.
don't rub.
Wear socks or stocking with raised
Wear wide roe-box or custom-made
seams.
shoes if foot deformities exist.
Place hands in shoes for inspection,
Inspect rhe inside of shoes for any
if sensory neuropathy is present
objects, [acks, or torn linings before
in the hands. Instead shake our
putting on the shoes.
the shoes for any objects.
Sources: Data from \'(1M Burch (cd). Endocrinology for the House Officer (2nd cd).
Baltimore: Williams & Wilkins, 1988;59: and JA Mayfield, GE Reiber, LJ Sanders.
Preventive foot care in people with diabetes. Diabetes Care 2001 ;24( I ):556.
The most common diabetic neuropathy is peripheral symmetric
polyneuropathy. Sensory deficits are greater than motor deficits and
occur in a glove-and-stocking pattern, resulting in a loss of pinprick
and light-touch sensations in these areas. However, patients will commonly present with a mixture of these three primary types of neuropathies. Foot ulcers and footdrop are common manifestations of diabetic neuropathies.11.29,32.3J,43
Table 11-11 outlines the signs and symptoms of the different types
of diabetic neuropathy.