Nursing Measurements Guide
A Guide to Deep Tendon Reflexes
In this edition of our diabetes series, we’ll be experiencing a wild adventure with the Pirates of the Pancreas, over the islets of Langerhans, to find the treasure maps and cannons that are vital in one’s existence.
In short, think of this lecture as an exploration of your pancreas, its essential parts, and its role in the development of diabetes.
The Adventure Begins
We’ll be associating this lecture to a pirate adventure to make it easier for us to explain and easier for you to remember each structure’s purpose and responsibility.
This portion is called “Pirates of the Pancreas” primarily because the pancreas is shaped like a small island and when discussed, is like taking a quick adventure in discovery of its different essential components. So, expect terms like treasure maps, volcanoes, cannons, and their medical term counterparts that are entirely intertwined with the pancreas.
The Volcanoes: Islets of Langerhans
So, you ask, “Why are islets of Langerhans compared to volcanoes?” It’s because the islets of Langerhans look like small volcanoes from an overhead perspective. Islet of Langerhans basically shoot out essential hormones.
Points to remember about the islets of Langerhans
- Beta cells, the ones responsible for producing insulin, are located in the islets of Langerhans.
- Glucagon, the hormone that takes out stored glycogen from the liver, can also be seen in the islets of Langerhans.
The Cannons: Enzymes
The actual tissue of the pancreas, or the island itself, is the one creating the enzymes or what we refer to as the cannons of our pirates. What do cannons do? They go ba-boom! With that in mind, the enzymes (cannons) that break down protein, lipids, and carbohydrates are the following:
- Protein – Protease
- Lipids – Lipase
- Carbohydrates – Amylase
Amylase is also present in human saliva which is why carbohydrate metabolism and breakdown initially happens inside the mouth. But, majority of where carbohydrate gets broken down is inside the gastrointestinal tract, specifically in the pancreas.
Here’s a quick overview on how people use the food they eat and what normally happens inside the body when nutrients and minerals are introduced.
So, when a person eats something, it goes inside the stomach. Once the pancreas recognizes the introduction of food, it will release enzymes to digest whatever was ingested, whether it’s protein, fats or carbohydrates, or a combination of all three.
The enzymes metabolize and break down the protein, lipids, and carbohydrates to aid in proper digestion of food by the body, which initially happens initially inside the duodenum. The duodenum is the first part of the small intestine and is situated right after the stomach.
Diagnosing Pancreatic Problems
The pancreas is near the liver and the gallbladder, so technically, there is a lot of action going on regarding digestive interaction. Therefore, if a client comes in complaining about abdominal pain, it has to take a couple of diagnostic studies to determine what main organ is affected.
Say for example, when diagnosing pancreatitis, a lot of these enzymes – protease, lipase, and amylase – are usually involved and are the bases for diagnosing if there’s something wrong with the tissue.
Hormones of the Islets of Langerhans: Glucagon and Insulin
Glucagon and insulin are two hormones that are secreted by the volcanoes (islets of Langerhans). Glucagon and insulin are essential in maintaining normal blood sugar levels. These two hormones are also referred to as the counter-regulatory hormones which means that they are the on-and-off switch for specific elements inside the body. In this case, it would be switch for the facilitation of blood glucose.
Insulin acts like a key. It is the hormone responsible for “opening up” the cell to allow sugar to come through and be converted into energy. From the bloodstream, insulin takes sugar and takes it inside the cell. This mechanism helps to decrease blood sugar levels in the bloodstream.
Unlike insulin which decreases sugar in the bloodstream, glucagon, on the other hand, increases the sugar level in the bloodstream by breaking down glycogen. Glucagon is useful when people require an increased amount of sugar, more than their body’s usual utilization, specifically those who are actively involved in any type of sports like marathons.
The Stored Treasure: Glycogen Wall
What does glucagon break down? It’s the stored treasure called glucose. Glucose gets stored in the body and is used when necessary, during rainy days, or when the body needs more supply of sugar in the bloodstream. Athletes or those people who are involved in sports or outdoor activities carb-load the day before the event. Carb-loading is eating a lot of carbohydrates so that the body would have an ample amount of stored glucose on the day of the event.
Most of the stored sugar in the body is deposited as fat. However, the first phase of the body storing sugar is when it creates a glycogen wall. A glycogen wall is composed of glucose bricks. The process of building the glycogen wall is termed as “glycogenesis” while the breaking down of the wall is called “glycogenolysis.”
Take note that “genesis” in the Bible means the creation. On the other hand, “-lysis” technically means to break something down, which, in this case, is the glycogen wall.
- Glycogenesis – build a wall
- Glycogenolysis – break a wall
Transforming Sugar into Energy
As previously mentioned, insulin serves as the key that lets glucose enter the cell. Once insulin has done its job – letting glucose into the cell – the cell transforms the glucose into energy and the body uses it for its daily activities. In this case, glucose serves as the body’s fuel.
Cells create energy by breaking down glucose into two pyruvates. Pyruvates go through the citric acid cycle or the Krebs cycle to pump out little carbon bonds to create adenosine triphosphate (ATP). This cycle is possible with the presence of oxygen which is also known as aerobic metabolism.
Let’s say, you’re running a marathon and your body is utilizing glucose to fuel your system. The body will break down the pyruvates, but there’s an insufficient amount of oxygen available to sustain the requirement. The body will then go into anaerobic metabolism. Without oxygen to facilitate the creation of ATP in the body, lactic acid will take its place.
Clients who have high levels of lactate acid in the body would most likely interpret that lactic acid was used instead of oxygen to create energy.
How would you know if your body is using oxygen or lactic acid when creating energy?
The body will experience soreness after strenuous activity. Which is why, it is necessary to observe moderation when engaging in sports or fitness activities during the first month of exposure or training because the lungs need to adjust and expand to accommodate enough oxygen.
The body gets sore because lactic acid burns the muscles. To prevent this from happening, more oxygen is required. Hydration is essential to alleviate the soreness. So, that’s a little tidbit for sports buffs and athletes.
Fat as Fuel
The body’s primary fuel is glucose. Fat, on the other hand, can be considered as the secondary fuel, which is more like diesel. If the body uses fat as its fuel, there will be increased ketones in the system. An Atkins diet is a typical example of the body using fat as its primary fuel because the diet insists on ingesting low carbohydrates and increased protein. Therefore, the body will utilize fat as its primary fuel and increased ketones will become apparent in the urine.
One of the major disadvantages of using fat as fuel is that it feels very dirty. The body will feel cloudy, like burning diesel which yields a lot of smoke when utilized.
Diabetes Lecture: Hypoglycemia and Hyperglycemia
There will be moments wherein the body will become hypoglycemic. Hypoglycemia or the state of having low blood sugar is a normal occurrence especially if you’ve missed a meal or you didn’t get enough sugar to sustain your activities that require the use of more energy.
The normal blood sugar is between 70 to 105 mg/dl. If the body’s blood sugar goes below that normal range, that’s the time that the acronym HIWASH comes in. For those who are unaware, HIWASH stands for:
Sugar is essential to the brain to function properly since it does not produce sugar by itself. Insufficient amount of glucose in the body can lead to brain deficits, and the body will experience the abovementioned HIWASH warning signs.
Nurses should be aware of these signs, especially with diabetic clients because if their sugar level goes down to less than 40 mg/dl, they can go into a diabetic coma.
Compared to hypoglycemia, hyperglycemia is much less critical in a way that you can think of it as an overfilled fuel tank wherein you will have gasoline all over the place, but it won’t break down the car immediately. There is sufficient time to correct hyperglycemia, unlike with hypoglycemia that is more perilous if not resolved or treated immediately.
Going back to our normal blood sugar level in the bloodstream, the ceiling would be 105 mg/dl. When a person eats, the blood sugar is expected to rise beyond 105 mg/dl, reaching around 130 to 150 mg/dl. Still, those numbers are considered within the therapeutic range. However, if the body maintains 150 mg/dl and goes up to 200 or more, and it becomes consistent for years without getting diagnosed, problems would eventually arise.
Undiagnosed persistent hyperglycemia would result in thick, syrupy blood flowing throughout the body, directly affecting the brain, heart, eyes, kidneys, and even the fingertips. Once syrupy blood reaches those parts of the body, destruction will occur.
Consequences of hyperglycemia are:
- Optic nerve affectation that can lead to blindness
- Kidney failure
- Decreased oxygen in the distal portions (toes and fingers) resulting in neuropathy
So remember, nobody immediately dies with hyperglycemia, but if it is not treated the soonest time possible, it will lead to a more pressing issue inside the body which is also known as diabetes.
The Three P’s of Hyperglycemia
Hyperglycemia has three signs and symptoms that nurses must watch-out-for:
- Polyuria – frequent urination
- Polydipsia – excessive thirst
- Polyphagia – excessive hunger
To easily remember that, we have translated the three P’s into:
- Pee – having the urge to urinate constantly
- Pepsi – wanting to drink more
- Plates – wanting to eat more
Due to increased blood sugar level, the body has the urge to expel unnecessary, syrupy blood in the form of urine. Therefore, the body would crave for fluid to dilute the blood and eliminate sugar concentration in the blood.
Pepsi is contraindicated with hyperglycemic clients; we just placed it there for you to easily remember that diabetics have this intense craving for fluid. This happens to be the main reason why polyuria happens.
Hyperglycemic clients are constantly starving even if there’s increased sugar in the bloodstream. The cells are supposed to use that sugar in the blood to produce energy; since glucose is not going inside the cells, they become hungry because glucose is not introduced due to lack or absence of insulin. There is no key to open the cell doors and let glucose in to be transformed into energy.
Types of Diabetes
There are two types of diabetes: type 1 and type 2.
Type 1 Diabetes
Going back to the pirates of the pancreas, the saltwater is representative of the blood with high levels of sugar. You’re on a pirate ship without means of filtering the saltwater, same with your cells that don’t have enough insulin to let glucose in. That’s the entire scenario with type 1 diabetes – there is no or insufficient amount of insulin to accommodate huge amounts of sugar in the bloodstream.
The decline in insulin production is primarily due to beta cells not doing what they’re supposed to. And remember, beta cells are found in the islets of Langerhans. Beta cells secrete insulin ,and without it, there won’t be the facilitation of insulin production. For this reason, type 1 diabetes clients require injectable insulin.
Insulin is never given orally or intramuscularly. Instead, insulin is administered:
Type 1 Diabetes and DKA
One of the major complications of type 1 diabetes is diabetic ketoacidosis (DKA) which is caused by ketones. There are three S’s that cause DKA, namely:
Type 2 Diabetes
With this type of diabetes, you have to keep in mind that the body is already resistant to insulin, and this is due to an overworked pancreas. To explain this condition further, let’s go back to the Pirates of the Pancreas analogy.
Let’s pretend that the pirates came to the pancreas and went to the islets of Langerhans, taking the resources of the island, and at the same time, over stimulating the islet of Langerhans.
Overstimulated beta cells inside the islets of Langerhans can lead to an increased insulin production which results to the cells no longer responding to the insulin; thus, no glucose is going inside the cells. The body no longer recognizes insulin and becomes insulin-resistant.
One of the main reasons why there is an overworked pancreas is due to a person’s diet – high sugar, high cholesterol, and high fat. Increased amounts of simple carbohydrates can do a lot of damage in the system, specifically in the pancreas.
Type 2 Diabetes and HHNS
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a severe complication of type 2 diabetes. This threatening condition is due to severely increased amounts of sugar in the blood. One of the main manifestations is polyuria that can lead to dehydration.
For your nursing management, you have to remind your clients to have better-eating habits, particularly lessening foods high in carbohydrates.
Here are two great ways to distinguish and remember which one leads to DKA or HHNS.
- In the English alphabet, D comes before H; therefore, type 1 is for DKA and type 2 is for HHNS.
- Between DKA and HHNS, which one has lower glucose? In reference to #1, since DKA came first, it has the lesser glucose level. HHNS, on the other hand, can even reach 300 mg/dl and above.
So, this is pretty much everything you need to know about the Pirates of the Pancreas. We hope this made it easier for you to remember the vital information required for you to pass your major exams.
In our next article, we’ll go into pancreatitis. See you there!