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DIABETIS MELLITUS

Diabetes Mellitus
A group of diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action or
both

Pancreas
 Glucagon
o Alpha cells of Islets of Langerhans
o s. glucose levels (gluconeogenesis)
 Insulin
o Beta cells of Islets of Langerhans
o s. glucose levels:
 Transcellular membrane transport of glucose
 Inhibits breakdown of fats and protein

Functions of Insulin
1. Transports and metabolizes glucose for energy
2. Stimulates storage of glucose in the liver and muscle as glycogen
3. Enhances the storage of dietary fat in adipose tissue
4. Inhibits the breakdown of stored glucose, protein, and fat

Classifications of Diabetes
1. Type 1 diabetes
2. Type 2 diabetes
3. Gestational diabetes
4. Diabetes mellitus associated with other conditions or syndromes

Type 1 Diabetes
 Insulin-producing beta cells in the pancreas are destroyed by an autoimmune process;
immunologic and possibly environmental (viral) factors
 Requires insulin, as little or no insulin is produced
 Onset is acute and usually occurs before age 30
 5% to 10% of persons with diabetes

Type 2 Diabetes
 Decreased sensitivity to insulin (insulin resistance) and impaired beta cell function results in
decreased insulin production
 Type 2: family history of diabetes, obesity, race/ ethnicity, age greater than 45 years,
previously identified impaired fasting glucose or impaired glucose tolerance, hypertension
≥140/90, HDL ≤35, and/or triglycerides ≥250, history of gestational diabetes, and babies
over 9 pounds

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 90% to 95% of person with diabetes

 More common in persons over age 30 and in the obese
 Treated initially with diet and exercise
 Oral hypoglycemic agents and insulin may be used

Diagnostic Findings
 Fasting blood glucose of 126 mg/dL or more
 Random glucose exceeding 200 mg/dL
 Glycosylated Hgb
o Most accurate
o Reflects s. CHO levels for the past 3 – 4 mos.

Excess glucose in the blood


Attach to hemoglobin

Hgb (components of rbc)
(Lifespan is 90 – 120 days)

What's a Normal Hemoglobin A1c Test?

 hgbA1c test is between 4% and 5.6%. Brunner (4-6%)
 Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of diabetes
 and levels of 6.5% or higher indicate diabetes
 the goal for people with diabetes is a hemoglobin A1c less than 7%.
 The higher the hbA1c, the higher the risks of dev complications rel to diabetes.

2PPBS
 Initial blood specimen is withdrawn
 100 g. of carbohydrate in diet
 2 after meal blood specimen is withdrawn – blood sugar returns to normal level

OGTT / GTT (Oral Glucose Tolerance Test)

o Take high CHO diet (200- 300 g) for 3 days
o Avoid alcohol, coffee, and smoking for 36 hours
o NPO for10- 16 hours
o Initial urine & blood specimen are collected
o 150 – 300 g. of CHO / p.o./IV
o Series of blood specimen is collected:
 30 mins.
 1
 2 - S. CHO returns to normal

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 3
 4
 5
 Done when results of FBS / 2PPBS are borderline (high normal)

Diabetes Mellitus (DM) Types

Type I Type II

 IDDM  NIDDM
 Juvenile – onset  Maturity – onset Stable DM
 Brittle DM  Ketosis – resistant DM
 Unstable DM   40 yrs.
  30 yrs.  With insulin sec.,  demands
 Absolute Insulin deficiency  Obesed
 Thin  Prone to HHNC
 Prone to DKA
 Management:  Management:
 Diet  Diet
 Activity/ Exercise  Activity/ Exercise
 Insulin  OHA
 Insulin – stress, surgery,
infections, pregnancy

Clinical Manifestations
 “Three Ps”
o Polyuria
o Polydipsia
o Polyphagia
 Fatigue, weakness, vision changes, tingling or numbness in hands or feet, dry skin, skin lesions
or wounds that are slow to heal, and recurrent infections
 Type 1 may have sudden weight loss, nausea, vomiting, and abdominal pain if DKA has
developed

Treatment Goal
 to normalize Blood Glucose Levels
 Intensive control dramatically decreases vascular and neuropathic complications

Dietary Management Goals

 Provide optimal nutrition including all essential food constituents
 Meet energy needs
 Achieve and maintain a reasonable weight
 Prevent wide fluctuations of blood glucose levels
 Decrease serum lipids, if elevated

Meal Planning

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 Consider food preferences, lifestyle, usual eating times, and cultural/ethnic background
 Carbohydrates: 50% to 60% carbohydrates, emphasize whole grains
 Fat: 20% to 30%, with >10% from saturated fat and >300 mg cholesterol
 Fiber Eating whole fruits rather than juices decreases the glycemic response due to fiber-
slowing absorption
 Provide exchange lists

Exercise
 Lowers blood sugar
 Aids in weight loss
 Lowers cardiovascular risk

Exercise Precautions
 Exercise when blood sugar levels are elevated (above 250 mg/dL) and ketones are present in
urine should be avoided
 Insulin normally decreases with exercise; patients on exogenous insulin should eat a 15-g
carbohydrate snack before moderate exercise to prevent hypoglycemia
 If exercising to control or reduce weight, insulin must be adjusted
 Potential exists for post exercise hypoglycemia
 Need to monitor blood glucose levels

Exercise Recommendations
 Encourage regular daily exercise
 Gradual increase in exercise period is encouraged
 Modify exercise regimen to patient needs and presence of diabetic complications or potential
cardiovascular problems
 Conduct exercise stress test for patients older than age 30 who have 2 or more risk factors is
recommended

Management:

Medications:
1. OHA
 Used for patients with Type 2 diabetes who cannot be treated with diet and exercise alone
 Combinations of oral drugs may be used
 Major side effects: hypoglycemia
o Stimulates I of L to secrete insulin
o Indicated only in Type 2 DM
E.g.
 Metformin Hcl (Glucophage) first line med
 Orinase
 Tolinase
 Micronase

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 Dymelor
 Glucotrol
 Diamicron

 Observe for s/sx of G.I. Upset

o Hypoglycemia

2. Insulin
1) Rapid – Acting: Clear insulin
 Regular
 Humulin – R
 Semilente
 Crystalline zinc
 Actrapid
 Onset: 30 mins. - 1
 Peak: 2 – 4
 Duration: 6 – 8

2) Intermediate - Acting
 Cloudy
o NPH
o Humulin – N
o Lente
o Monotard
 Onset: 1 - 2
 Peak: 6 - 8
 Duration: 18 - 24

3)Long Acting: Cloudy

o PZI
o Ultralente
o Onset : 3 - 4
o Peak : 16 - 20
o Duration : 30 – 36

Nursing Responsibilities on Insulin Therapy

1. Route: SC – slow absorption

IV – DKA
SC - 90L thin: 3/8”
obese: ½”, 5/8”
Do not massage site of injection

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2. Administer insulin at room temperature

Cold Insulin  LIPODYSTROPHY
3. Rotate the site to prevent lipodystrophy
4. Store vial of insulin in current use @ room temperature
 Other vials should be refrigerated.
5. Gently roll vial in between the palms to redistribute insulin particles.
 Do not Shake; bubbles make it difficult to aspirate exact amount.

6. Generalized
 Edema
o Sudden resolution of hyperglycemia

retention of water

 Hypoglycemia
o Prolonged
 doses of INSULIN Tx

 s. CHO levels

Stress responses are triggered
Counterregulatory hormones are secreted
(EPI, NE, Glucocorticoid)

REBOUND HYPERGLYCEMIA
Somogyi phenomenon

 Dawn’s Phenomenon
Nightime Normoglycemia

Increased GH secretion
( 12 mn- 3 AM)

Early AM Hyperglycemia

Acute Complications of Diabetes

 Hypoglycemia
 Diabetic ketoacidosis (DKA)
 Hyperglycemic hyperosmolar nonketotic syndrome (HHNS), or hyperosmolar nonketotic coma,
or hyperglycemia hyperosmolar syndrome (HHS)

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Hypoglycemia
 Abnormally low blood glucose level (below 50 to 60 mg/dL)
 Causes include too much insulin or oral hypoglycemic agents, too little food, and excessive
physical activity
 Manifestations
o Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, and
hunger
o CNS symptoms: inability to concentrate, headache, confusion, memory lapses, slurred
speech, numbness of lips and tongue, irrational or combative behavior, double vision,
and drowsiness
Severe hypoglycemia may cause disorientation, seizures, and loss of consciousness
 Onset is abrupt and may be unexpected
 Symptoms vary from person to person

Assessment:
 Restlessness
 Hunger pangs
 Yawning
 Weakness
 Tremors
 Pallor
 Diaphoresis
 Altered LOC
 Cold, clammy skin
 H/A
 Dizziness
 Faintness
 Tachycardia
 Abdominal pain
 Blurred vision
 Slurred speech
 Urine (-) CHO,ketones

Management:
1. Simple Sugars p.o.
o 3 – 4oz. regular softdrink
o 8 oz. Fruit juice
o 5 – 7 pcs. Lifesaver’s candies
o 3 – 4 pcs. hard candies
o 1 tbsp. Sugar

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o 5 mls. Pure honey / Karo syrup

o 10 – 15 gms. CHO
2. D50W 20 –50 mls / IV push
3. Monitor BS
4. Patient teaching
o Causes
o S & Sx
o Prevention
o Management
5. Treatment must be immediate
6. Give 15 g of fast-acting, concentrated carbohydrate
o 3 or 4 glucose tablets
o 4 to 6 ounces of juice or regular soda (not diet soda)
o 6 to 10 hard candies
o 2 to 3 teaspoons of honey
7. Retest blood glucose in 15 minutes, retreat if >70 mg/dL or if symptoms persist more than
10 to 15 minutes and testing is not possible
8. Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within
30 to 60 minutes

Emergency Measures:
 If the patient cannot swallow or is unconscious:
o Subcutaneous or intramuscular glucagon 1 mg
o 25 to 50 mL 50% dextrose solution IV

Diabetic Ketoacidosis (DKA)

 Caused by an absence of or inadequate amount of insulin resulting in abnormal metabolism of
carbohydrate, protein, and fat
 Clinical features (KKK)
 Hyperglycemia
 Dehydration
 Acidosis
 Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia,
abdominal pain, nausea, vomiting, acetone breath, hyperventilation with Kussmaul respirations,
and mental status changes

Assessment
 Blood glucose levels vary between 300 to 800 mg/ dL
 Ketoacidosis is reflected in low serum bicarbonate and low pH; low PCO reflects
2
respiratory compensation
 Ketone bodies in blood and urine

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Treatment of DKA
 Rehydration with IV fluid
 IV continuous infusion of regular insulin
 Reverse acidosis and restoration of electrolyte balance

Note: rehydration leads to increased plasma volume and decreased K+; insulin enhances the
movement of K+ from extracellular fluid into the cells

 Monitor
o Blood glucose and renal function/UO
o EKG and potassium
o VS, lung assessments, signs of fluid overload

Assessment of Hyperglycemia
 Polyuria
 Polydipsia
 Polyphagia
 Warm, flushed dry skin
 Soft eyeballs
 Tachycardia
 n/v
 Abdominal pain
 Kussmaul’s resp.
 Fruity odor of breath
 Urine (+) CHO, Ketones
 Altered LOC
Management of Hyperglycemia
 NSS + regular insulin / IV
 KCl / Slow IV drip, once urine output is adequate
 Patient teaching
 Causes
 S & Sx
 Prevention
 Management

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

 Hyperosmolality and hyperglycemia occur due to lack of effective insulin; ketosis is minimal or
absent
 Hyperglycemia causes osmotic diuresis with loss of water and electrolytes; hypernatremia and
increased osmolality occur

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 Manifestations include hypotension, profound dehydration, tachycardia, and variable

neurologic signs due to cerebral dehydration
 High mortality

Treatment of HHNS
 Rehydration
 Insulin administration
 Monitor fluid volume and electrolyte status
 Prevention:
o BGSM

Long Term Complications of Diabetes

 Macrovascular complications
o Accelerated atherosclerotic changes
o Coronary artery disease
 Microvascular complications
o Diabetic retinopathy
o Nephropathy
 Neuropathic changes
o Peripheral neuripathy
o Autonomic neuropathies, sexual dysfunction

Foot Care
 Assess skin daily
 Provide diabetic foot care:
o Position legs and feet, keeping heels off bed; use a bed cradle
o Wash feet with warm water and mild soap.
o Pat dry the feet – X rub
o Wear comfortable properly – fitted pair of shoes (leather/ canvass)
o Break – in new pair of shoes for 1 – 2 only until it becomes comfortable.
o Use white cotton socks (males)
o X go barefooted
o Trim the toenails straight across. Do not cut at lateral edges, ingrowns may develop.
o Exercise / massage the feet.
o X wear knee – high / stay – up stockings
o For any s & sx of injury; consult a PODIATRIST.

Diabetes Mellitus