Diabetes Mellitus

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1
2011
 Definition

Diabetes mellitus is defined as a chronic

metabolic disorder characterized by
hyperglycemia resulting from defect in insulin
secretion, insulin action or both.

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 Diabetes Mellitus

• Leading cause of heart disease, stroke, adult blindness,

and non traumatic lower limb amputations

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 Causes
• Genetic factors
• Autoimmune diseases
• Viral infections
• Environmental factors [stress]
• Obesity [increases the chance by 20%]
• Use of medications [steroids, antihypertensives etc]
• Injury to the pancreas [infection, surgery, tumour, trauma etc]
• Age [risk increases with increased age]
• Use f alcohol and smoking.

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 Diabetes Mellitus
Etiology and Pathophysiology

• Normal insulin metabolism

• Produced by the  cells in the islets of
Langherans of the pancreas
• Facilitates normal glucose range of 70
to 120 mg/dl

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• Normal insulin metabolism
• Promotes glucose transport from the
bloodstream across the cell membrane
to the cytoplasm of the cell

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• Normal insulin metabolism
•  Insulin after a meal:
• Stimulates storage of glucose as
glycogen
• Inhibits gluconeogenesis
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• Normal insulin metabolism
•  Insulin after a meal:
• Enhances fat deposition in adipose
tissue
• Increases protein synthesis
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 Types of diabetes mellitus

• Type I DM [IDDM]
• Type II DM [NIDDM]
• Gestational diabetes
• Prediabetes
• Secondary diabetes

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 Type 1 Diabetes Mellitus

• Formerly known as “juvenile onset” or “insulin

dependent” diabetes
• Most often occurs in people under 30 years of age
• Peak onset between ages 11 and 13.
• Progressive destruction of pancreatic  cells
• Autoantibodies cause a reduction of 80% to 90% of
normal  cell function before manifestations occur
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• Causes:
• Genetic predisposition
• Related to human leukocyte antigens (HLAs)
• Exposure to a virus
• Manifestations develop when the pancreas can
no longer produce insulin
• Rapid onset of symptoms
• Weight loss
• Polydipsia
• Polyuria
• Polyphagia

• Present at ER with ketoacidosis

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 Type 2 Diabetes Mellitus

• Accounts for 90% of patients with diabetes

• Usually occurs in people over 40 years of age
• 80-90% of patients are overweight

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 Type 2 Diabetes Mellitus
Etiology and Pathophysiology

• Pancreas continues to produce some endogenous

insulin
• Insulin produced is either insufficient or poorly
utilized by the tissues.
• Insulin resistance
• Body tissues do not respond to insulin
• Results in hyperglycemia 13/04/2011 14
• Impaired glucose tolerance (IGT)
• Occurs when the alteration in  cell function is
mild
• Blood glucose levels are higher than normal but
not high enough for a diagnosis of diabetes.
• Inappropriate glucose production by the liver
• Not considered a primary factor in the
development of type 2 diabetes

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• Insulin resistance syndrome (syndrome X)
• Cluster of abnormalities that act synergistically
to  the risk of cardiovascular disease.
• Gradual onset
• Person may go many years with undetected
hyperglycemia
• Marked hyperglycemia (500 to 1000 mg/dl)

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 3. Gestational Diabetes

• Develops during pregnancy

• Detected at 24 to 28 weeks of gestation
•  Risk for cesarean delivery, perinatal death, and neonatal
complications

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 4. Prediabetes
• Prediabetes is also known as impaired glucose tolerance
[IGT] r impaired fasting glucose.
• It is a condition in which the blood glucose levels are
higher than normal [>100mg/dl] but <126mg/dl but not
high enough for a diagnosis f diabetes.
• People with prediabetes are at increased risk of type 2
diabetes.
• Preventive measures are not taken these patients will
develop DM within next 10 years.
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 5. Secondary Diabetes

• Results from another medical condition or due to the

treatment of a medical condition that causes abnormal
blood glucose levels
• Cushing syndrome
• Hyperthyroidism
• Parenteral nutrition

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 Clinical Manifestations
Type 2 Diabetes Mellitus
• Acute in onset [rapid]
• Polyuria
• Polydipsia (excessive thirst)
• Polyphagia
• Weight loss
• Weakness and fatigue
• Ketoacidosis

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 Clinical Manifestations
Type 2 Diabetes Mellitus

• Non-specific symptoms and gradual slow) nset

• Classic symptoms of diabetes [polyuria, polydipsia, polyphagia]
• Fatigue
• Recurrent infections
• Prolonged wound healing
• Visual changes

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 Diagnostic Studies

• Fasting plasma glucose level 126 mg/dl

• Random plasma glucose measurement
200 mg/dl plus symptoms
• Two-hour OGTT level 200 mg/dl using a glucose load of
75 g

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• Impaired glucose tolerance (IGT)
• Fasting blood glucose level 110 mg/dl but less than 126
mg/dl
• Hemoglobin A1C test:
• Measures blood levels over 2-3 months (per text)
• High levels of glucose will attach to hemoglobin
• Helps to ensure that the patient’s gluco-meter is accurate.

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 Collaborative Care

• Goals of diabetes management:

• Reduce symptoms
• Promote well-being
• Prevent acute complications
• Delay onset and progression of long-term
complications
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 Collaborative Care

• Patient teaching
• Nutritional therapy
• Drug therapy
• Exercise
• Self-monitoring of blood glucose

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 Drug Therapy: Insulin

• Exogenous insulin:
• Required for type 1 diabetes
• Prescribed for the patient with type 2 diabetes who
cannot control blood glucose by other means

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• Types of insulin
• Human insulin
• Most widely used type of insulin
• Cost-effective
•  Likelihood of allergic reaction

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• Types of insulin
• Insulins differ in regard to onset, peak action,
and duration
• Different types of insulin may be used for
combination therapy

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• Types of insulin
• Rapid-acting: Lispro (onset 15’, peak 60-90’ and
last from 2-4 hours)
• Short-acting: Regular (Onset is 30-60’, peak in 2-
3h and last for 4-6 hours, and Regular insulin is only
kind for IV use.
• Intermediate-acting: NPH or Lente. Onset 3-4h,
peak 4-12 hours and lst 16-20 hours. Names include
Humulin N, Novolin N, Humulin L, Novolin L

• Long-acting: Ultralente, Lantus

Onset 6-8h, peak 12-16 h and lasts 20-30h.
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• Administration of insulin
• Cannot be taken orally
• SQ injection for self-administration
• IV administration
• Insulin Strengths
• 100 U per mL or 500 U per mL
• Administered in a sterile, single-use, disposable
syringe
• All insulin given parenterally
• Regular insulin: either subcutaneous or intravenous
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• Injection Sites
• Process: pinch skin, inject needle at 90-
degree angle
• Do not inject into muscle; do not
massage after injecting
• Rotate injection sites
• Minimize painful injections

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Injection Sites

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Fig. 47-5
• Problems with insulin therapy
• Hypoglycemia
• Allergic reactions
• Lipodystrophy
• Lipodystrophy: is a medical condition
characterized by abnormal or degenerative
conditions of the body's adipose tissue.
• Lipoatrophy: is the term describing the localized
loss of fat tissue.

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 Drug Therapy: Oral Agents

• Also called OHA. It is not insulin

• Work to improve the mechanisms in which insulin and glucose
are produced and used by the body.
• They are
• Sulfonylureas: Glipizide, Glyburide and Glimepiride
• Meglitinides: Prandin & Starlix
• Biguanides: Metformin
• -Glucosidase inhibitors: Acarbose. Delay absorption of CHO
• Thiazolidinediones: Pioglitazone (Actos) 13/04/2011 37
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 2. Sulfonylureas
• Increased insulin production by the pancreas.
• Enhance cellular sensitivity to insulin
• Hypoglycemia and weight gain are common s/e
• The common drugs are Glipizides, glyburide,
glimepiride

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 3. Meglitinides

• Increases insulin production

• Common drugs are nateglinide and rapaglinide
• Take these drugs 30 minutes before meal.
• Should not be taken when meal is skipped as it may result
in hypoglycemia

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 4. α glucosidase inhibitors

• Also known as starch blockers

• Slows down the absorption of glucose in small
intestine
• Acarbose and miglitol
• Taken with first bite of each meal
• Effective in reducing postprandial glucose

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 5. Thiazolidinediones

• Also called insulin sensitizers

• Pioglitazone and rosiglitazone
• Effcetive in type 2 with insulin resistance
• Can cause heart failure and bladder cancer

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 6. Dipeptidyl peptidase – 4
inhibitors
• Also known as gliptins
• Stimulate production of insulin by beta cells.
• Linagliptin, sitagliptin, alogliptin etc

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• Other drugs affecting blood glucose levels:
• -Adrenergic blockers
• Thiazide
• Loop diuretics

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 Nutritional Therapy

• American Diabetes Association (ADA)

• Guidelines indicate that within the context of an
overall healthy eating plan, a person with
diabetes can eat the same foods as a person who
does not have diabetes.

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• American Diabetes Association (ADA)
• Overall goal:
• Assist people in making changes in nutrition
and exercise habits that will lead to improved
metabolic control

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• Type 1 DM
• Meal plan based on the individual’s usual food
intake and is balanced with insulin and
exercise patterns.
• Type 2 DM
• Emphasis placed on achieving glucose, lipid,
and blood pressure goals
• Calorie reduction

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• Food composition
• Individual meal plan developed with a dietitian
• Nutritionally balanced
• Does not prohibit the consumption of any one
type of food.
• Avoid Alcohol
• High in calories
• Promotes hypertriglyceridemia
• Can cause severe hypoglycemia
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• Diet teaching
• Dietitian initially provides instruction
• Should include the patient’s family and significant
others.
• Total CHO minimum of 130gm/day
• Fiber intake at 25 – 30gm/day
• Protein 15 to 20% of total calories
• Limit saturated fat to less than 7% of total calories
• Dietary cholesterol less than 200mg/day
• Limit alcohol consumption [2 drinks/13/04/2011
day] 49
• Exercise
• Essential part of diabetes management
• Increases insulin sensitivity
• Lowers blood glucose levels
• Decreases insulin resistance

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 Exercise
• Regular and consistent exercise is important.
• At least 150minutes/week or 30minutes 5days/week.
• Activities includes brisk walk, swimming, bicycling,
dancing, aerobic exercises etc
• Several small carbohydrate snacks can be taken every 30
minutes during exercise to prevent hypoglycemia.
• Best done after meals
• Exercise plans should be individualized
• Monitor blood glucose levels before, during, and after
exercise. 13/04/2011 51
 Monitoring Blood Glucose

• Self-monitoring of blood glucose (SMBG)

• Enables patient to make self-management
decisions regarding diet, exercise, and
medications.
• Important for detecting episodic hyperglycemia
and hypoglycemia
• Patient training is crucial
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 Diabetic foot care
• Wash feet everyday with luke warm water and soap.
• Dry the feet well, between the toes.
• Moisturize the feet
• Inspect the feet for any cut, blisters or sores
• Keep the toe nails short
• Wear clean socks which should not be too tight or too loose.
• Use a correct fitting shoes
• Never walk bare foot
• Podiatry visit
•
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 Surgical management

• Bariatric surgery
• Pancreas transplantation

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 Bariatric surgery

• Bariatric surgery (or weight loss surgery) includes a

variety of procedures performed on people who have obesity.
• Weight loss is achieved by reducing the size of the stomach
with a gastric band or through removal of a portion of the
stomach or by resecting and re-routing the small intestine to
a small stomach pouch.
• Considered for patients with type 2 DM
• BMI above 35kg/m2
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 Pancreas Transplantation

• Used for patients with type 1 diabetes who

have end-stage renal disease and who have
had or plan to have a kidney transplant.
• Eliminates the need for exogenous insulin
• Can also eliminate hypoglycemia and
hyperglycemia 13/04/2011 56
 New Developments in Diabetic
Therapy

• New insulin delivery systems not yet approved by the FDA:

• Inhaled insulin
• Skin patch
• Oral spray
• Insulin pills
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 Nursing Management
Nursing Assessment

• Viral infections
• Medications
• Recent surgery
• Positive health history
• Obesity

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• Weight loss
• Thirst
• Hunger
• Poor healing
• Kussmaul respirations: Deep, rapid respiration
characteristic of diabetic acidosis or other conditions
causing acidosis. 13/04/2011 59
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 Nursing Diagnoses

• Ineffective therapeutic regimen management

• Fatigue
• Risk for infection
• Powerlessness

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• Risk for Unstable Blood Glucose may be related to
• Inadequate blood glucose monitoring
• Lack of adherence to diabetes management
• Medication management
• Deficient knowledge of diabetes management
• Developmental level
• Lack of acceptance of diagnosis
• Stress
• Sedentary activity level
• Insulin deficiency or excess

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• Deficient Knowledge related to 
• Unfamiliarity with insulin injection
• Dietary modifications
• Exercise for normoglycemia
• Unfamiliarity with information
• Interpretation

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• Risk for Infection related to
• High glucose levels,
• decreased leukocyte function,
• alterations in circulation
• Preexisting respiratory infection, or UTI

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• Risk for Disturbed Sensory Perception related to
• Endogenous chemical alteration:
• glucose/insulin and/or electrolyte imbalance

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• Powerlessness related to
• Long-term/progressive illness that is not curable
• Dependence on others

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• Ineffective Therapeutic Regimen Management
related to
• New-onset diabetes
• Lack of knowledge about diabetes and its
management
• Complex medical regimen

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• Risk for injury related to
• Hyperglycemia
• Peripheral sensory neuropathy
• Autonomic neuropathy
• Immune system deficit
• Vascular insufficiency

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• Imbalanced Nutrition: Less Than Body
Requirements related to
• Insulin deficiency (decreased uptake and utilization of
glucose by the tissues, resulting in increased
protein/fat metabolism)
• Decreased oral intake: anorexia, nausea, gastric
fullness, abdominal pain; altered consciousness
• Hypermetabolic state: release of stress hormones (e.g.,
epinephrine, cortisol, and growth hormone), infectious
process

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• Risk for Deficient Fluid Volume related to
• Osmotic diuresis (from hyperglycemia)
• Excessive gastric losses: diarrhea, vomiting
• Restricted intake: nausea, confusion

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• Fatigue related to
• Decreased metabolic energy production
• Altered body chemistry: insufficient insulin
• Increased energy demands: hypermetabolic
state/infection

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• Risk for Impaired Skin Integrity related to
decreased circulation and sensation caused by
peripheral neuropathy and arterial obstruction.

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 Nursing Management
Planning

• Overall goals:
• Active patient participation
• No episodes of acute hyperglycemic emergencies or
hypoglycemia.
• Maintain normal blood glucose levels
• Prevent chronic complications
• Lifestyle adjustment with minimal stress
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 Nursing Management
Nursing Implementation

• Health Promotion
• Identify those at risk
• Routine screening for overweight adults over
age 45

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THANK YOU

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