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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.