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Organisation and planning of care

1. Careful planning, taking into account the specific needs of
the patient with diabetes, is required at all stages of the patient
pathway from GP referral to post-operative discharge.
2. The patient should be involved in planning for all stages.
3. Hospital patient administration systems should be able to
identify all patients with diabetes so they can be prioritized on
the operating list.
4. High-risk patients (poor glycaemic control/complications of
diabetes) should be identified in surgical outpatients or at preoperative assessment and plans should be put in place to
manage their risk.
5. Early pre-operative assessment should be arranged to
determine a peri-operative diabetes management strategy and
to identify and optimize other co-morbidities.
6. Routine overnight admission for pre-operative management
of diabetes should not be necessary.
7. Starvation time should be minimized by prioritizing patients
on the operating list.
8. Surgical and anesthetic principles of the Enhanced
Recovery Partnership Programme should be implemented to
promote earlier mobilization with resumption of normal diet
and return to usual diabetes management.
9. Multi-modal analgesia should be combined with appropriate
anti-emetics to enable an early return to normal diet and usual
diabetes regimen.
10. The patient should resume diabetes self management as
soon as possible where appropriate.
11. A policy which includes plans for diabetes management
should be in place for safe discharge.
12. Outcomes should be audited regularly.

Clear guidelines should indicate when the diabetes specialist team should become involved. 18. Peri-operative blood glucose monitoring 20.45% sodium chloride with 5% glucose and either 0. avoiding a VRIII wherever possible. 16. The recommended first choice substrate solution for a VRIII is 0. 14. 19.15% potassium chloride (KCl) or 0. All hospitals should implement a Diabetes Inpatient Specialist Nurse (DISN) service. 21. Training for blood glucose measurement and diabetes management should be introduced for clinical staff caring for patients with diabetes. Insulin should be prescribed according to National Patient Safety Agency (NPSA) recommendations for safe use of insulin.Diabetes specialists 13. 17. Patients with a planned short starvation period (no more than one missed meal in total) should be managed by modification of their usual diabetes medication. The WHO surgical safety checklist bundle should be . Peri-operative use of intravenous insulin 15. Capillary blood glucose (CBG) levels should be monitored and recorded at least hourly during the procedure and in the immediate postoperative period.3% KCl. 22. Patients expected to miss more than one meal should have a VRIII. The term ‘variable rate intravenous insulin infusion’ (VRIII) should replace the ambiguous term ‘sliding scale’. Hospitals should have clear guidelines for the management of blood glucose when it is outside the acceptable range. 23.

implemented. 24. . The target blood glucose should be 6-10 mmol/L (acceptable range 4-12 mmol/L).

Demonstrate and explain thoroughly the procedure for insulin self-injection Help patient to master technique by taking a stepby-step approach. Discuss the goals of dietary therapy for the patient. and identifying supportive coping techniques. and bedtime based on patient’s individualized insulin regimen. Setting a goal of a 10% (of patient’s actual body weight) weight loss over several months is usually achievable and effective in reducing blood sugar and other metabolic parameters. conveying a sense of empathy. Allow patient time to handle insulin and syringe to become familiar with the equipment. Caloric expenditure for energy in exercise Carryover of enhanced metabolic rate and efficient food utilization Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them. inability to eat •Activity Intolerance related to poor glucose control •Deficient Knowledge related to use of oral hypoglycemic agents •Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities •Ineffective Coping related to chronic disease and complex self-care regimen Nursing Intervention and Evaluation Nursing care plans for Diabetes Mellitus No 1 Nursing Diagnose Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures Outcome Nutrition balance between needs and intake Intervention • • • • • • • • • 2 Fear related to insulin injection Fear less or discrease • • • • • • • 3 Risk for Injury Injury is not (hypoglycemia) appears related to effects of insulin. fad diets or diet plans that stress one food group and eliminate another are generally not recommended. Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid Hypoglycemia identified and treated appropriately . Strategize with patient to address the potential social pitfalls of weight reduction. Advise patient on the importance of an individualized meal plan in meeting weight-loss goals. Explain the importance of exercise in maintaining/reducing body weight. however. Emphasize that lifestyle changes should be maintainable for life. Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. activity.Nursing Diagnosis Nursing care plans for Diabetes Mellitus Common nursing diagnosis found in Nursing care plans for Diabetes Mellitus •Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures •Fear related to insulin injection •Risk for Injury (hypoglycemia) related to effects of insulin. Review dosage and time of injections in relation to meals. Instruct patient in filling syringe when he or she expresses confidence in self-injection procedure. Evaluation Maintains ideal body weight with body mass index less than 25 Assist patient to reduce fear of injection by encouraging verbalization of fears regarding insulin injection. Demonstrates self-injection of insulin with minimal fear Closely monitor blood glucose levels to detect hypoglycemia. Teach self-injection first to alleviate fear of pain from injection. • • Assess current timing and content of meals. Reducing intake of carbohydrates may benefit some patients.

medication treatment. Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency. blurred vision Verbalizes appropriate use and action of oral hypoglycemic agents . pallor. Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency. slurred speech. Encourage patient to carry a portable treatment for hypoglycemia at all times. Advise patient to assess blood glucose level before and after strenuous exercise. Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia. Adrenergic (early symptoms) sweating. confusion. irritability. Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin. Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia. tremor. Patient should contact health care provider if levels remain elevated. Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin. headache. polyphagia. palpitations. Assess patient for the signs and symptoms of hypoglycemia. staggering gait from depression of central nervous system as glucose level progressively falls Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates. monitoring procedures. and exercise regimen Assess for signs of hyperglycemia: polyuria. weight loss. Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia. Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia. Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised. Exercises daily Assess level of knowledge of disease and ability to care for self Assess adherence to diet therapy. polydipsia. tachycardia. Instruct patient to plan exercises on a regular basis each day. fatigue. Encourage patient to carry a portable treatment for hypoglycemia at all times. lack of coordination. nervousness from the release of adrenalin when blood glucose falls rapidly Neurologic (later symptoms) light-headedness. Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present.inability to eat • • • • • • • • • • • • 4 Activity Intolerance related to poor glucose control Normal Activity is appears • • • • • • 5 Deficient Knowledge related to use of oral hypoglycemic agents Knowledge is• sufficient • • hypoglycemia.

• • • • • • • • 6 Risk for Impaired Impaired Skin• Skin Integrity Integrity is related to not appears decreased • sensation and • circulation to lower extremities • • • • 7 Ineffective Effective Coping related to coping chronic disease and complex selfcare regimen • • • • • Assess for signs of hypoglycemia: sweating. dryness. Instruct patient in foot care guidelines Advise the patient who smokes to stop smoking or reduce if possible. muscle weakness. and altered level of consciousness) or hyperosmolar hyperglycemic nonketotic syndrome (nausea and vomiting. warmth. special mattresses. hammer toe or bunion deformation. tremor. Avoid applying drying agents to skin (eg. Maintain skin integrity by protecting feet from breakdown. Apply skin moisturizers to maintain suppleness and prevent cracking and fissures. Assist family in providing emotional support. family life. light-headedness. stupor. Kussmaul respirations. Help patient to establish behavior modification techniques to eliminate smoking in the hospital and to continue them at home for smoking-cessation program. seizures. confusion Perform thorough skin and extremity assessment for peripheral neuropathy or peripheral vascular disease and any injury to the feet or lower extremities Assess for trends in blood glucose and other laboratory results Make sure that appropriate insulin dosage is given at the right time and in relation to meals and exercise Make sure patient has adequate knowledge of diet. sensation. and medication treatment Immediately report to health care provider any signs of skin or soft tissue infection (redness. to reduce vasoconstriction and enhance peripheral blood flow. foot cradles for patients on bed rest. tachycardia. Assess feet and legs for skin temperature. soft tissue injuries. No skin breakdown Discuss with the patient the perceived effect of diabetes on lifestyle. nervousness. alcohol). deep tendon reflexes. Verbalizes initial strategies for coping with diabetes . corns. finances. hypotension. Explore previous coping strategies and skills that have had positive effects. hypothermia. tenderness. fruity breath odor. pulses. Identify available support groups to assist in lifestyle adaptation. calluses. coma). hair distribution. Use heel protectors. occupation. swelling. exercise. Encourage patient and family participation in diabetes self-care regimen to foster confidence. drainage) Get help immediately for signs of hypoglycemia that do not respond to usual glucose replacement Get help immediately for patient presenting with signs of either ketoacidosis (nausea and vomiting.

Nursing Diagnosis : Risk for Infection related to hyperglikemia. 5. Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual patients. this cooperation can be pursued after discharge. Rational: high glucose levels in blood would be the best medium for the growth of germs.) Provide fluid therapy as indicated. 5.) Weigh weight per day or as indicated. 2). skin turgor. Rational: Assessing an adequate food intake (including absorption and utilization). 2. Nursing Intervention: 1. 3. Maintain aseptic technique in invasive procedures. Rationale: Identify deficiencies and deviations from the therapeutic needs. and effectiveness of the therapy given. 2. 4).) Measure weight every day. Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid. Rational: This is an indicator of the level of dehydration. Rationale: Prevents cross infection.Nursing Diagnosis and Nursing Intervention Nursing Diagnosis for Diabetes Mellitus 1. renal function.) Monitor input and output. Rational: hypovolemia can be manifested by hypotension and tachycardia. Goal: Identify interventions to prevent / reduce the risk of infection. 2. Nursing Intervention: 1). 3. 4.) Involve patients in planning the family meal as indicated. Nursing Diagnosis : Fluid Volume Deficit related to osmotic diuresis. palpable peripheral pulse. capillary refill.) Give regular insulin treatment as indicated. 3). lifestyle changes to prevent infection. skin turgor and capillary refill well. individually appropriate urinary output. and electrolyte levels within normal limits. decreased oral input. Nursing Intervention: 1. Rational: regular insulin has a rapid onset and quickly and therefore can help move glucose into cells. and mucous membranes. Improve efforts to prevention by good hand washing for all people in contact with patients including the patients themselves. Demonstrate techniques. 4. Goal: Digest the amount of calories / nutrients right Shows the energy level is usually Stable or increasing weight. .) Determine the patient's diet and eating patterns and compared with food that can be spent by the patient. Rationale: Increase the sense of involvement. Observed signs of infection and inflammation. provide information on the family to understand the patient's nutrition. Rational: If the patient's food preferences can be included in meal planning. Goal: Demonstrate adequate hydration evidenced by stable vital signs.) Assess peripheral pulses. Rationale: Patients may be entered with an infection that usually has sparked a state of ketoacidosis or may have nosocomial infections.) Monitor vital signs.) Identification of preferred food / desired include the needs of ethnic / cultural. Rational: To provide estimates of the need for fluid replacement. Give your skin with regular care and earnest. or an adequate circulating volume. Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirmentsrelated to insufficiency of insulin. 3. record the specific gravity of urine.

Assess patient's level of mobility. promote optimal physical activity. which is necessary before setting realistic goals. 4.. Activity Intolerance Activity Intolerance Definition : Insufficient physiological or psychological energy to endure or complete required or desired daily activities Activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. walker. 3.Rational: the peripheral circulation may be disturbed that puts patients at increased risk of damage to the skin / skin irritation and infection. Assess potential for physical injury with activity. Some aids may require more energy expenditure for patients who have reduced upper arm strength (e. •Need for oxygen with increased activity Portable pulse oximetry can be used to assess for oxygen desaturation.g. 5). Assess nutritional status. malnourishment. or pulmonary. 2. This is especially apparent in elderly patients with a history of orthopedic. Make changes to the position. side effects of medications (e.. and assist the patient to maintain a satisfactory lifestyle. walking with crutches). Assess patient's cardiopulmonary status before activity using the following measures: •Heart rate Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. •How Valsalva maneuver affects heart rate when patient moves in bed Valsalva maneuver. Supplemental oxygen may help compensate for the increased oxygen demands. 4. . This number will change depending on the intensity of exercise the patient is attempting (e. Beta-blockers). Related Factors: •Generalized weakness •Deconditioned state •Sedentary lifestyle •Insufficient sleep or rest periods •Depression or lack of motivation •Prolonged bed rest •Imposed activity restriction •Imbalance between oxygen supply and demand •Pain •Side effects of medications Nursing Interventions for Activity Intolerance 1. •Orthostatic BP changes Elderly patients are more prone to drops in blood pressure with position changes. Assess need for ambulation aids: bracing. Adequate energy reserves are required for activity.related problems. which requires breath holding and bearing down. Injury may be related to falls or overexertion. Nursing goals are to reduce the effects of inactivity. cane. equipment modification for activities of daily living (ADLs).g. cardiopulmonary. or emotional states such as depression or lack of confidence to exert one's self. Activity intolerance may also be related to factors such as obesity. This aids in defining what patient is capable of. can cause bradycardia and related reduced cardiac output. Adequate assessment of energy requirements is indicated. The aging process itself causes reduction in muscle strength and function.g. diabetic. which can impair the ability to maintain activity.. effective coughing and encourage deep breathing. climbing four flights of stairs versus shoveling snow). Rational: memventilasi Assist in all areas and mobilize pulmonary secretions.

Monitor pulse. Fatigue Nursing Diagnosis: Fatigue May be related to •Decreased metabolic energy production •Altered body chemistry: insufficient insulin •Increased energy demands: hypermetabolic state/infection Possibly evidenced by •Overwhelming lack of energy. Increases confidence level/self-esteem and tolerance level. and BP before/after activity. Prevents excessive fatigue. expenditure of energy. Difficulties sleeping need to be addressed before activity progression can be achieved. •Display improved ability to participate in desired activities. expressions of having no control/influence over situation . accidentprone •Impaired ability to concentrate. Determine patient's perception of causes of fatigue or activity intolerance. Assessment guides treatment. Discuss ways of conserving energy while bathing. Indicates physiological levels of tolerance. Education may provide motivation to increase activity level even though patient may feel too weak initially. Nursing Interventions Rationale Discuss with patient the need for activity. and Patient will be able to accomplish more with a decreased so on. listlessness. disinterest in surroundings Desired Outcomes •Verbalize increase in energy level. decreased performance. Plan schedule with patient and identify activities that lead to fatigue. Increase patient participation in ADLs as tolerated. Monitor patient's sleep pattern and amount of sleep achieved over past few days.6. physical or psychological. transferring. Alternate activity with periods of rest/uninterrupted sleep. Powerlessness Nursing Diagnosis: Powerlessness May be related to •Long-term/progressive illness that is not curable •Dependence on others Possibly evidenced by •Reluctance to express true feelings. inability to maintain usual routines. These may be temporary or permanent. respiratory rate.

Knowledge of individual’s style helps determine needs for treatment goals. Unrealistic expectations/pressure from others or self may result in feelings of frustration/loss of control and may impair coping abilities. Risk for Disturbed Sensory Perception Nursing Diagnosis: Sensory Perception. Acknowledge normality of feelings. Patient who operates with an external locus of control wants to be cared for by others and may project blame for circumstances onto external factors. Development of psychological concerns/visceral neuropathies affecting selfconcept (especially sexual role function) may add further stress. •Identify healthy ways to deal with feelings. Determine whether a change in relationship with SO has occurred. Patient whose locus of control is internal usually looks at ways to gain control over own treatment program. withdrawal. nonparticipation in care/decision making •Depression over physical deterioration/complications despite patient cooperation with regimen Desired Outcomes: •Acknowledge feelings of helplessness. Provide opportunity for SO to express Enhances sense of being involved and gives SO a chance to problem-solve solutions to help concerns and discuss ways in which he patient prevent recurrence.•Apathy.g. Ascertain expectations/goals of patient and SO. Promotes feeling of control over situation. Identify locus of control. or she can be helpful to patient. Assess how patient has handled problems in the past. •Assist in planning own care and independently take responsibility for self-care activities. Encourage patient to make decisions related to care. Communicates to patient that some control can be exercised over care. e. Identifies concerns and facilitates problem solving. time for activities. Recognition that reactions are normal can help patient problem-solve and seek help as needed. anger •Does not monitor progress. Support participation in self-care and give positive feedback for efforts. Nursing Interventions Rationale Encourage patient/SO to express feelings about hospitalization and disease in general. ambulation. and so forth. risk for disturbed (specify) Risk factors may include •Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance Desired Outcomes . Diabetic control is a full-time job that serves as a constant reminder of both presence of disease and threat to patient’s health/life.. Constant energy and thought required for diabetic control often shifts the focus of a relationship.

e.g. BUN/Cr. •Recognize and compensate for existing sensory impairments. Reduces discomfort and potential for dermal injury. and time. fever may affect mentation. Place bed in low position. decreased leukocyte function.g. Protect patient from injury (avoid/limit use of restraints as able) when level of consciousness is impaired. Address patient by name. Carry out prescribed regimen for correcting DKA as indicated. Rationale Provides a baseline from which to compare abnormal findings. pain. potentiating risk of dermal injury and impaired balance. Schedule nursing time to provide for uninterrupted rest periods. Give short explanations. Helps keep patient in touch with reality and maintain orientation to the environment. aspiration. person. alterations in circulation •Preexisting respiratory infection. Alteration in thought processes/potential for seizure activity is usually alleviated once hyperosmolar state is corrected. reorient as needed to place. Nursing Interventions Monitor vital signs and mental status. blood glucose. excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication). loss of pedal pulses. Peripheral neuropathies may result in severe discomfort. avoiding exposure to cool drafts/hot water or use of heating pad. Promotes patient safety. Keep hands/feet warm. speaking slowly and enunciating clearly. Disoriented patient is prone to injury. Retinal edema/detachment. Decreases confusion and helps maintain contact with reality. Monitor laboratory values. Evaluate visual acuity as indicated. lack of/distortion of tactile sensation. especially at night. Risk for Infection Nursing Diagnosis: Risk for Infection Risk factors may include: •High glucose levels. Assist with ambulation/position changes. presence of cataracts or temporary paralysis of extraocular muscles may impair vision. Keep patient’s routine as consistent as possible. Investigate reports of hyperesthesia. Promotes restful sleep. Look for ulcers.. Provide bed cradle. hemorrhage. reddened areas. Hb/Hct. and precautions need to be taken as indicated. Imbalances can impair mentation.•Maintain usual level of mentation. serum osmolality. Seizure precautions need to be taken as appropriate to prevent physical injury. and may improve cognition. e.. or UTI . Encourage participation in activities of daily living (ADLs) as able. reduces fatigue. Note: If fluid is replaced too quickly. pressure points. especially when sense of balance is affected. requiring corrective therapy and/or supportive care. Pad bed rails and provide soft airway if patient is prone to seizures. or sensory loss in the feet/legs.

•Demonstrate techniques. Reposition and encourage coughing/deep breathing if Aids in ventilating all lung areas and mobilizing secretions. wound drainage. flushed appearance. suction secretions with increased risk of infection. reducing bacteria growth and flushing organisms out of system. Promote good handwashing by staff and patient. Place in semi-Fowler’s position. purulent sputum. Encourage/assist with oral hygiene. maintenance/site care. Otherwise. lifestyle changes to prevent development of infection. Maintain aseptic technique for IV insertion procedure. Minimizes spread of infection. Increased urinary flow prevents stasis and aids in maintaining urine pH/acidity. Rhonchi indicate accumulation of secretions possibly related to pneumonia/bronchitis (may have precipitated the DKA). cloudy urine. Keep the skin dry. Expected outcomes: Perform the necessary procedures and explain the rationale of an action. reduces risk of aspiration. Rotate IV sites as indicated. Patient may be admitted with infection. Administer antibiotics as appropriate. Provide catheter/perineal care. which could have precipitated the ketoacidotic state. procedures and effects of the treatment process. placing patient at increased risk for skin areas. as needed.Desired Outcomes: •Identify interventions to prevent/reduce risk of infection. Encourage adequate dietary and fluid intake (approximately3000 mL/day if not contraindicated by cardiac or renal dysfunction). Provide conscientious skin care. Auscultate breath sounds. using sterile technique. Decreases susceptibility to infection. fever. Nursing Interventions Rationale Observe for signs of infection and inflammation. and providing High glucose in the blood creates an excellent medium for bacterial growth. e. Facilitates lung expansion. Note: Use of cranberry juice can help prevent bacteria from adhering to the bladder wall. Comatose patient may be at particular risk if urinary retention occurred before hospitalization. irritation/breakdown and infection. Pulmonary congestion/edema (crackles) may result from rapid fluid replacement/HF.. Instruct patient in proper handling of secretions. or may develop a nosocomial infection. gently massage bony Peripheral circulation may be impaired. airway. Early treatment may help prevent sepsis. Reduces risk of oral/gum disease. Note: Elderly female diabetic patients are especially prone to urinary tract/vaginal yeast infections. administration of medications. Knowledge Deficit Goal: patient expressed understanding of the conditions. 5. Provide tissues and trash bag in a convenient location for sputum and other secretions. Teach the female patient to clean from front to back after elimination Minimizes risk of UTI. . linens dry and wrinkle-free. Reduces risk of cross-contamination.g. Prevents stasis of patient is alert and cooperative. reducing the risk of recurrent UTI. including 8 oz of cranberry juice per day as appropriate.

5) Other: Pramlintide lowers glucose by suppressing glucagon and slowing gastric emptying. The major classifications of diabetes are: •Type 1 diabetes (insulin dependent diabetes mellitus) is caused by B-cell destruction. Therefore. 2)Drugs that alter insulin action: Metformin works in the liver. R: Find out how much experience and knowledge of the client and family about the disease. R: Knowing how much understanding of clients and their families and assess the success of the action taken. The thiazolidinediones appear to have their main effect on skeletal muscle and adipose tissue.Initiate the necessary lifestyle changes and participate in treatment regimen. Encourage clients and families to pay attention to her diet. Assess the level of knowledge of the client and family about the disease. and treatment. 3)Drugs that principally affect absorption of glucose: The glucosidase inhibitors acarbose and miglitol are such currently available drugs. Drugs for Treating Hyperglycemia The drugs for treating type 2 diabetes fall into several categories: 1)Drugs that primarily stimulate insulin secretion by binding to the sulfonylurea receptor. Sulfonylureas remain the most widely prescribed drugs for treating hyperglycemia. the therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia and without seriously disrupting the patient’s usual lifestyle and activity. The meglitinide analog repaglinide and the D-phenylalanine derivative nateglinide also bind the sulfonylurea receptor and stimulate insulin secretion. 3. usually leading to absolute insulin deficiency a) Immune mediated b) Idiopathic •Type 2 diabetes (previously referred to as non insulin dependent diabetes mellitus) ranges from those with predominant . clients and their families will feel calm and reduce anxiety. 2. MANAGEMENT DIABETES MANAGEMENT The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications. R: Diet and proper diet helps the healing process. Give an explanation to the client about diseases and conditions now. R: By knowing the diseases and conditions now. There are five components of diabetes management • Nutritional management • Exercise • Monitoring • Pharmacologic therapy • Education Classification of Diabetes Mellitus There are several different types of diabetes mellitus. clinical course. Intervention / Implementation: 1. Ask the client and reiterated family of materials that have been given. 4. Insulin Insulin is indicated for type 1 diabetes as well as for type 2 diabetic patients with insulinopenia whose hyperglycemia does not respond to diet therapy either alone or combined with other hypoglycemic drugs. they may differ in cause. 4) Drugs that mimic incretin effect or prolong incretin action: Exenatide and DPP 1V inhibitors fall into this category.

Conditions or situations known to exacerbate glucose/insulin imbalance include (1) previously undiagnosed or newly diagnosed type 1 diabetes. and these patients are prone to ketoacidosis. It also stimulates protein synthesis and free fatty acid storage. controls the level of glucose in the blood by regulating the production and storage of glucose. The resulting hyperglycemia can damage many of the body’s organs and tissues. Type 1 diabetes can be complicated by instability and diabetic ketoacidosis (DKA). demail@adis. Type 2 diabetes is the more prevalent form and results from insulin resistance with a defect in compensatory insulin secretion Insulin. S o u r c e Goa KL. or emotional distress. adrenal . which antagonize insulin •metabolic syndrome. Insulin deficiency or resistance compromises the body tissues’ access to essential nutrients for fuel and storage.000 new cases of diabetes are diagnosed annually in the general population. 1997 Jun.insulin resistance associated with relative insulin trauma. and (5) stress associated with illness. Risk Factors For Diabetes Mellitus Include: •Obesity. which is considered a precursor to the development of type 2 diabetes mellitus •some medications that can antagonize the effects of insulin. (4) exercise in uncontrolled diabetes. A review of its pharmacology and use in the management of the complications of diabetes mellitus. Lisinopril. and approximately 625. a hormone produced by the pancreas. Haria M. PHARMACOLOGY MANAGEMENT Drugs.53(6):1081-105. although genetic factors may play a role. Adis International Limited. infection. (3) adolescence and puberty. Diabetes mellitus results from insulin deficiency or resistance. DKA is a life-threatening emergency caused by a relative or absolute deficiency of insulin. which can cause prolonged elevation of stress hormone levels. •pregnancy. Insulin transports glucose into the cell for use as energy and storage as glycogen. Auckland. Wilde MI. •Physiologic or emotional stress. which causes weight gain and increases levels of estrogen and placental hormones. Type 1 diabetes is due to pancreatic islet B cell destruction predominantly by an autoimmune process. and hormonal contraceptives Statistics Diabetes affects 18% of people over the age of 65. including thiazide diuretics. New Zealand. to those with a predominantly insulin secretory defect with insulin resistance Causes for Diabetes Mellitus The cause of both type 1 and type 2 diabetes remains unknown. (2) food intake in excess of available insulin.

and no conclusions can yet be made about its use in patients with normoalbuminuria. like other ACE inhibitors. In addition. On available evidence. These findings. as shown in the EUCLID trial. provides new data supporting an additional place in managing normotensive patients with microalbuminuria and IDDM. suggest a broader role for the drug in managing diabetic vascular complications. post hoc analysis of the GISSI-3 trial indicates that lisinopril reduces 6-week mortality rates in diabetic patients when begun as early treatment after an acute myocardial infarction. the GISSI-3 study indicates that the incidence of persistent hypotension and renal dysfunction is increased with lisinopril in general. Progression to retinopathy was slowed during 2 years' lisinopril therapy in the EUCLID study. As shown by the EUCLID (EUrodiab Controlled trial of Lisinopril in Insulin-Dependent Diabetes) trial. using lisinopril.Abstract Lisinopril. The drug may also improve neurological function. In complications other than nephropathy. The tolerability profile of lisinopril is typical of ACE inhibitors and appears to be similar in diabetic and nondiabetic individuals. lowers blood pressure and preserves renal function in hypertensive patients with non-insulin-dependent or insulin-dependent diabetes mellitus (NIDDM or IDDM) and early or overt nephropathy. lisinopril has shown some benefit. despite similar antihypertensive efficacy. renoprotective effects appear to be greater with lisinopril than with comparator calcium channel blockers. but the presence of diabetes does not appear to confer additional risk of these events in diabetic patients with acute myocardial infarction receiving lisinopril. lisinopril lowers blood pressure and produces a renoprotective effect in patients with IDDM and NIDDM without detriment to glycaemic control or lipid profiles. In summary. diuretics and betablockers. Like other ACE inhibitors. The effect in normotensive patients with normoalbuminuria was smaller than in those with microalbuminuria. Although not yet fully published. Hypoglycaemia has occurred at a similar frequency with lisinopril and placebo. lisinopril should thus be viewed as a firstline agent for reducing blood pressure and preventing or attenuating nephropathy in hypertensive diabetic patients with IDDM or NIDDM and microalbuminuria or overt renal disease. Lastly. MANAGEMENT . without adversely affecting glycaemic control or lipid profiles. The EUCLID study. together with some evidence for an effect of lisinopril in delaying progression of retinopathy and in reducing mortality. lisinopril is also renoprotective in normotensive patients with IDDM and microalbuminuria. these results provide the most convincing evidence to date for an effect of an ACE inhibitor in retinopathy. but this finding is preliminary.