INTRODUCTION:

Diabetes mellitus is a condition in which the pancreas no longer produces enough

insulin or cells stop responding to the insulin that is produced, so that glucose in the
blood cannot be absorbed into the cells of the body. Symptoms include frequent
urination, lethargy, excessive thirst, and hunger. The treatment includes changes in
diet, oral medications, and in some cases, daily injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or
adult-onset diabetes, and this form of diabetes occurs most often in people who are
overweight and who do not exercise. Type II is considered a milder form of diabetes
because of its slow onset (sometimes developing over the course of several years)
and because it usually can be controlled with diet and oral medication. The
consequences of uncontrolled and untreated Type II diabetes, however, are the just
as serious as those for Type I. This form is also called noninsulin-dependent
diabetes, a term that is somewhat misleading. Many people with Type II diabetes
can control the condition with diet and oral medications, however, insulin injections
are sometimes necessary if treatment with diet and oral medication is not working.

The causes of diabetes mellitus are unclear, however, there seem to be both
hereditary (genetic factors passed on in families) and environmental factors
involved. Research has shown that some people who develop diabetes have
common genetic markers. In Type I diabetes, the immune system, the bodys
defense system against infection, is believed to be triggered by a virus or another
microorganism that destroys cells in the pancreas that produce insulin. In Type II
diabetes, age, obesity, and family history of diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells have
become resistant to the insulin produced and it may not work as effectively.
Symptoms of Type II diabetes can begin so gradually that a person may not know
that he or she has it. Early signs are lethargy, extreme thirst, and frequent
urination. Other symptoms may include sudden weight loss, slow wound healing,
urinary tract infections, gum disease, or blurred vision. It is not unusual for Type II

diabetes to be detected while a patient is seeing a doctor about another health

concern that is actually being caused by the yet undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include
people who:
are obese (more than 20% above their ideal body weight)
have a relative with diabetes mellitus
belong to a high-risk ethnic population (African-American, Native American,
Hispanic, or Native Hawaiian)
have been diagnosed with gestational diabetes or have delivered a baby weighing
more than 9 lbs (4 kg)
have high blood pressure (140/90 mmHg or above)
have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL
and/or a triglyceride level greater than or equal to 250 mg/dL
have had impaired glucose tolerance or impaired fasting glucose on previous testing

Diabetes mellitus is a common chronic disease requiring lifelong behavioral and

lifestyle changes. It is best managed with a team approach to empower the client to
successfully manage the disease. As part of the team the, the nurse plans,
organizes, and coordinates care among the various health disciplines involved;
provides care and education and promotes the clients health and well being.
Diabetes is a major public health worldwide. Its complications cause many
devastating health problems.

ANATOMY AND PHYSIOLOGY:

Every cell in the human body needs energy in order to function. The bodys primary
energy source is glucose, a simple sugar resulting from the digestion of foods
containing carbohydrates (sugars and starches). Glucose from the digested food
circulates in the blood as a ready energy source for any cells that need it. Insulin is
a hormone or chemical produced by cells in the pancreas, an organ located behind
the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a
key to open a doorway into the cell through which glucose can enter. Some of the
glucose can be converted to concentrated energy sources like glycogen or fatty

acids and saved for later use. When there is not enough insulin produced or when
the doorway no longer recognizes the insulin key, glucose stays in the blood rather
entering the cells.

PATHOPHYSIOLOGY:

DIAGNOSTIC TEST:

Several blood tests are used to measure blood glucose levels, the primary test for
diagnosing diabetes. Additional tests can determine the type of diabetes and its
severity.
Random blood glucose test for a random blood glucose test, blood can be drawn
at any time throughout the day, regardless of when the person last ate. A random
blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have

symptoms of high blood glucose (see Symptoms above) suggests a diagnosis of

diabetes.
Fasting blood glucose test fasting blood glucose testing involves measuring blood
glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal
fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126
mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small
sample of blood from a vein or fingertip. It must be repeated on another day to
confirm that it remains abnormally high (see Criteria for diagnosis below).
Hemoglobin A1C test (A1C) The A1C blood test measures the average blood
glucose level during the past two to three months. It is used to monitor blood
glucose control in people with known diabetes, but is not normally used to diagnose
diabetes. Normal values for A1C are 4 to 6 percent (show figure 3). The test is done
by taking a small sample of blood from a vein or fingertip.
Oral glucose tolerance test Oral glucose tolerance testing (OGTT) is the most
sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not
routinely recommended because it is inconvenient compared to a fasting blood
glucose test.

The standard OGTT includes a fasting blood glucose test. The person then drinks a
75 gram liquid glucose solution (which tastes very sweet, and is usually cola or
orange-flavored). Two hours later, a second blood glucose level is measured.

Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of

pregnancy to screen for gestational diabetes; this requires drinking a 50 gram
glucose solution with a blood glucose level drawn one hour later. For women who
have an abnormally elevated blood glucose level, a second OGTT is performed on
another day after drinking a 100 gram glucose solution. The blood glucose level is
measured before, and at one, two, and three hours after drinking the solution.

MEDICATIONS:

When diet, exercise and maintaining a healthy weight arent enough, you may need
the help of medication. Medications used to treat diabetes include insulin. Everyone
with type 1 diabetes and some people with type 2 diabetes must take insulin every
day to replace what their pancreas is unable to produce. Unfortunately, insulin cant
be taken in pill form because enzymes in your stomach break it down so that it

becomes ineffective. For that reason, many people inject themselves with insulin
using a syringe or an insulin pen injector,a device that looks like a pen, except the
cartridge is filled with insulin. Others may use an insulin pump, which provides a
continuous supply of insulin, eliminating the need for daily shots.

The most widely used form of insulin is synthetic human insulin, which is chemically
identical to human insulin but manufactured in a laboratory. Unfortunately,
synthetic human insulin isnt perfect. One of its chief failings is that it doesnt mimic
the way natural insulin is secreted. But newer types of insulin, known as insulin
analogs, more closely resemble the way natural insulin acts in your body. Among
these are lispro (Humalog), insulin aspart (NovoLog) and glargine (Lantus).

A number of drug options exist for treating type 2 diabetes, including:

Sulfonylurea drugs. These medications stimulate your pancreas to produce and

release more insulin. For them to be effective, your pancreas must produce some
insulin on its own. Second-generation sulfonylureas such as glipizide (Glucotrol,
Glucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride
(Amaryl) are prescribed most often. The most common side effect of sulfonylureas is
low blood sugar, especially during the first four months of therapy. Youre at much
greater risk of low blood sugar if you have impaired liver or kidney function.

Meglitinides. These medications, such as repaglinide (Prandin), have effects similar

to sulfonylureas, but youre not as likely to develop low blood sugar. Meglitinides
work quickly, and the results fade rapidly.

Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class
available in the United States. It works by inhibiting the production and release of
glucose from your liver, which means you need less insulin to transport blood sugar
into your cells. One advantage of metformin is that is tends to cause less weight
gain than do other diabetes medications. Possible side effects include a metallic
taste in your mouth, loss of appetite, nausea or vomiting, abdominal bloating, or
pain, gas and diarrhea. These effects usually decrease over time and are less likely
to occur if you take the medication with food. A rare but serious side effect is lactic
acidosis, which results when lactic acid builds up in your body. Symptoms include
tiredness, weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is

especially likely to occur if you mix this medication with alcohol or have impaired
kidney function.

Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your

digestive tract that break down carbohydrates. That means sugar is absorbed into
your bloodstream more slowly, which helps prevent the rapid rise in blood sugar
that usually occurs right after a meal. Drugs in this class include acarbose (Precose)
and miglitol (Glyset). Although safe and effective, alpha-glucosidase inhibitors can
cause abdominal bloating, gas and diarrhea. If taken in high doses, they may also
cause reversible liver damage.

Thiazolidinediones. These drugs make your body tissues more sensitive to insulin
and keep your liver from overproducing glucose. Side effects of thiazolidinediones,
such as rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include
swelling, weight gain and fatigue. A far more serious potential side effect is liver
damage. The thiazolidinedione troglitzeone (Rezulin) was taken off the market in
March 2000 because it caused liver failure. If your doctor prescribes these drugs, its
important to have your liver checked every two months during the first year of
therapy. Contact your doctor immediately if you experience any of the signs and
symptoms of liver damage, such as nausea and vomiting, abdominal pain, loss of
appetite, dark urine, or yellowing of your skin and the whites of your eyes
(jaundice). These may not always be related to diabetes medications, but your
doctor will need to investigate all possible causes.

Drug combinations. By combining drugs from different classes, you may be able to
control your blood sugar in several different ways. Each class of oral medication can
be combined with drugs from any other class. Most doctors prescribe two drugs in
combination, although sometimes three drugs may be prescribed. Newer
medications, such as Glucovance, which contains both glyburide and metformin,
combine different oral drugs in a single tablet.

NURSING INTERVENTIONS:
Advice patient about the importance of an individualized meal plan in meeting
weekly weight loss goals and assist with compliance.

Assess patients for cognitive or sensory impairments, which may interfere with the
ability to accurately administer insulin.
Demonstrate and explain thoroughly the procedure for insulin self-injection. Help
patient to achieve mastery of technique by taking step by step approach.
Review dosage and time of injections in relation to meals, activity, and bedtime
based on patients individualized insulin regimen.
Instruct patient in the importance of accuracy of insulin preparation and meal
timing to avoid hypoglycemia.
Explain the importance of exercise in maintaining or reducing weight.
Advise patient to assess blood glucose level before strenuous activity and to eat
carbohydrate snack before exercising to avoid hypoglycemia.
Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns,
calluses, dryness, hair distribution, pulses and deep tendon reflexes.
Maintain skin integrity by protecting feet from breakdown.
Advice patient who smokes to stop smoking or reduce if possible, to reduce
vasoconstriction and enhance peripheral flow.