Assessment and

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

Affects nearly 29.1 million people in the United States

Almost 1/3 of cases are undiagnosed

Diabetes
Prevalence is increasing (1.7million are newly diagnosed
per year from 20 years old and above)

Minority populations and the elderly are

disproportionately affected
 Type 1 diabetes

Type 2 diabetes

Gestational diabetes
Classification
latent autoimmune diabetes of adults
(LADA)
Diabetes mellitus associated with other
conditions or syndromes
 • a hormone secreted by beta cells, which are one of four types of
cells in the islets of Langerhans in the pancreas

• When a person eats a meal, insulin secretion increases and moves

glucose from the blood into muscle, liver, and fat cells

FUNCTIONS
INSULIN • Transports and metabolizes glucose for energy
• Stimulates storage of glucose in the liver and muscle as glycogen
• Signals the liver to stop the release of glucose
• Enhances the storage of dietary fat in adipose tissue
• Accelerates transport of amino acids into cells
• Inhibits the breakdown of stored glucose, protein, and fat
 • secreted by the alpha cells of the islets of Langerhans
• released when blood glucose levels decrease
• stimulates the liver to release stored glucose
• Glycogenolysis
GLUCAGON
• breakdown of stored glucose
• Gluconeogenesis
• production of new glucose from amino acids and
other substrates
 Insulin producing beta cells in the pancreas
are destroyed by an autoimmune process

Requires insulin, as little or no insulin is

produced
Type 1
Diabetes Onset is acute and usually before 30 years
of age

Approx. 5% of persons with diabetes

 • Destruction of beta cells lead results in decrease insulin
and increased glucose production in the liver.
• Liver cannot store glucose then it remains in the
bloodstream
Osmotic diuresis • kidneys may not reabsorb all of the filtered glucose and
excreted through urine (glycosuria)
• Usually, glycosuria accompanied by excessive loss of
fluids and electrolytes
• This is called osmotic diuresis.
 Diabetic Ketoacidosis (DKA)

• a metabolic derangement that occurs most commonly in persons with type 1

diabetes and results from a deficiency of insulin

THREE MAJOR METABOLIC DERANGEMENTS

• Glycogenolysis and gluconeogenesis occur in an unrestrained fashion w/c
contribute further hyperglycemia
• Fat breakdowns also occur resulting to increase ketone bodies
• Increased ketones result to metabolic acidosis
 Type 2 Diabetes

• Decreased sensitivity to insulin (insulin resistance) and impaired beta cell function results in decreased
insulin production
• Approx. 95% of person with diabetes
• More common in persons over age 30 and in the obese
• Insulin related problems
• insulin resistance
• impaired insulin secretion
• Slow, progressive glucose intolerance
• Treated initially with diet and exercise
• Oral hypoglycemic agents and insulin may be used
 Hyperglycemic Hyperosmolar Syndrome
(HHS)
• 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.
• Manifestations include
• hypotension,
• profound dehydration,
• tachycardia, and
• variable neurologic signs due to cerebral dehydration.
• High mortality.
 Gestational Diabetes

• degree of glucose intolerance with its onset during pregnancy

• Occurs in 18% of pregnant women
• Risk factors:
• Obesity
• Family Hx. Of diabetes
• Ethnicity

• After delivery, blood glucose levels in women with gestational diabetes usually return to normal.
• However, many women who have had gestational diabetes develop type 2 diabetes later in life.
 Latent Autoimmune Diabetes of Adults
(LADA)

• a subtype of diabetes in which the progression of autoimmune beta cell

destruction in the pancreas is slower than in types 1 and 2 diabetes
• Not insulin dependent in the first 6 months of disease onset
• Signs and symptoms are similar to type 1 and 2 diabetes
 Clinical manifestations

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

• Fasting blood glucose 126 mg/dL(7.0mmol/L) or more

• Fasting is defined as no caloric intake for at least 8 hour

• Random glucose exceeding 200 mg/dL (11.1 mmol/L)

• any time of day without regard to time since last meal.

• 2-hour postload exceeding 200 mg/dL (11.1 mmol/L)

• Gerontologic considerations: age-related elevation of blood glucose

 Medical Management

• Main goal is to normalize insulin activity and blood glucose level to avoid further complications such as:
• Retinopathy
• Nephropathy
• Nueropathy
• Diabetes management has five components:
• nutritional therapy,
• exercise,
• monitoring,
• pharmacologic therapy, and
• education
 Nutritional therapy

• Diabetes management:
• Nutrition
• meal planning
• weight control

• control of total caloric intake

• Nurses and all other members of the health care team must be knowledgeable about nutritional
therapy and supportive of patients who need to implement nutritional and lifestyle changes
 Meal planning

• Consider food preferences, lifestyle, usual eating times, and cultural/ethnic

background
• Review diet history and need for weight loss, gain, or maintenance
• Caloric requirements and calorie distribution throughout the day
• Carbohydrates: 50–60% carbohydrates, emphasize whole grains
• Fat: 20–30%, with >10% from saturated fat and cholesterol< 300 mg/dl
• Protein – non animal sources
• Fiber
 Food Classification Systems

• Exchange lists
• bread/starch, vegetable, milk, meat, fruit, and fat
• Nutritional labels
• can be used to determine how much medication is needed.
• Healthy Food Choices
• alternative to counting grams of carbohydrate is measuring servings or choices
• MyPlate Food Guide
• commonly used for patients with type 2 diabetes who have a difficult time following a calorie-controlled diet
• Glycemic Index
• describe how much a given food increases the blood glucose level compared with an equivalent amount of glucose
 Glycemic Index

• Describes how much a food increases blood glucose

• Combine starchy food with protein and fat containing food slows absorption, and
glycemic response
• Raw or whole foods tend to have lower response than cooked, chopped, or pureed
foods
• Eat whole fruits rather than juices; decreases glycemic response due to fiber-
slowing absorption
• Adding food with sugars may produce lower response if eaten with foods that are
more slowly absorbed
 Other Dietary Concerns

• Alcohol consumptions
• sweeteners
• Misleading Food Labels
 Exercise

• Lowers blood sugar

• Aids in weight loss
• Lowers cardiovascular risk
 Exercise Recommendations

• Encourage regular daily exercise

• Gradual, slow increase in exercise period is encouraged
• Modify exercise regimen to patient needs and presence of diabetic
complications or potential cardiovascular problems
• Exercise stress test for patients older than age 30 who have 2 or more risk
factors is recommended
• Gerontologic considerations
 Exercise Precautions

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

• Self-Monitoring of blood glucose( SMBG): Enables people with DM to adjust the treatment regimen to
obtain optimal blood glucose control. Allow early detection of hypo and hyperglycemia and normalizing
blood glucose levels.
• Disadvantages of SMBG are in the need for good visual acuity, fine motor coordination, cognitive ability,
comfort with technology, willingness and cost
• Candidates for SMBG:
• Unstable DM
• A tendency for sever ketosis and hypoglycemia
• Hypoglycemia without warning symptoms
• Abnormal renal glucose threshold
• Frequency: 2-4 times per day is recommended (before meals and bedtime)
• Glucosylated Hemoglobin: HgbA1c (glucose control for 3 months)
• Urine testing for glucose
• Urine testing for Ketones (Ketonuria): should be performed whenever
patients with type 1 have glucosuria or persistently elevated blood glucose
levels ( more than 240mg/dl for two testing periods), and during illness and
pregnancy.
 Insulin Therapy

Blood glucose monitoring

• Categories of insulin
• Rapid-acting
• Short-acting
• Intermediate-acting
• Very long-acting
• Inhaled insulin
• Insulin therapy: taken one or two times per day( or even more often) to control
blood glucose. Accurate monitoring of blood glucose levels is essential

• Insulin preparations: - Time course: onset, peak, and duration of action ( rapid
acting (lispro), short acting (HR), intermediat-acting (NPH or Lent), Long acting
(Ultralent), and Mixed (70% NPH and 30% R)

• Source: beef, pork, and Human insulin which is now widly used
 Insulin Regimen

Conventional regimen:
• is to simplify the insulin regimen ( 1-2 injections/day).
• May be appropriate for the terminally ill, unwilling or unable to engage in the self-
management activities that are part of amore complex insulin regimen

Intensive regimen:
• 3-4 injection/day to achieve as much control over blood glucose levels as is safe and
practical and to decrease complications
 Complications of Insulin

• Systemic Allergic Reactions

• Insulin Lipodystrophy
• Resistance to Injected Insulin
• Morning Hyperglycemia.
Causes of Morning Hyperglycemia
 Methods of insulin delivery

• Insulin Pens
• Jet Injectors
• Insulin Pumps
Insulin syringes Insulin pump
 Oral Antidiabetic Agents

• 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 effect: hypoglycemia
• Nursing interventions: monitor blood glucose, and for hypoglycemia and
other potential side effects
• Patient teaching
 Types of oral antidiabetic agents

• first- and secondgeneration sulfonylureas

• biguanides,
• alpha-glucosidase inhibitors,
• nonsulfonylurea insulin secretogogues (meglitinides and phenylalanine derivatives)
• thiazolidinediones (glitazones),
• dipeptide peptidase-4 (DPP4) inhibitors,
• glucagon-like peptide-1 receptor agonists (GLP-1), and
• sodium-glucose cotransporter 2 (SGL2) inhibitors
 Sites of
Actions
of oral
antidiabetic
agents
 Acute Complications of Diabetes

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

• abnormally low blood glucose level (below 50–60 mg/dL)

• Causes
• too much insulin or oral hypoglycemic agents,
• too little food, and
• excessive physical activity
• Severe hypoglycemia may cause disorientation, seizures, and loss of consciousness
 Manifestations Adrenergic symptoms:

• sweating,
• tremors,
• tachycardia,
• palpitations,
• nervousness,
• hunger
 Central nervous system symptoms:

• inability to concentrate,
• headache,
• confusion,
• memory lapses,
• slurred speech,
• numbness of lips and tongue,
• irrational or combative behavior,
• double vision,
• drowsiness
 Assessment

• Onset is abrupt and may be unexpected

• Symptoms vary from person to person
• Symptoms also vary related to the rapidly of decrease in blood glucose and
usual blood glucose range
• Decreased adrenergic response may affect symptoms in persons who have
had diabetes for many years probably related to autonomic neuropathy
 Management of Hypoglycemia

• Treatment must be immediate

• Give 15 g of fast-acting, concentrated carbohydrate
• 3 or 4 glucose tablets
• 4–6 ounces of juice or regular soda (not diet soda)
• 6–10 hard candies
• 2–3 teaspoons of honey
• Retest blood glucose in 15 minutes, retreat if >70 mg/dL or if symptoms persist more than 10–15 minutes
and testing is not possible.
• Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30–60 minutes
 Emergency measure

•If the patient cannot swallow or is

unconscious:
•Subcutaneous or intramuscular glucagon
1 mg
•25–50 mL 50% dextrose solution IV
 Diabetic Ketoacidosis

• Caused by an absence of or inadequate amount of insulin resulting in

abnormal metabolism of carbohydrate, protein, and fat
• Clinical features
• Hyperglycemia
• Dehydration
• Acidosis
 Manifestations

• polyuria,
• polydipsia,
• blurred vision,
• weakness,
• headache,
• anorexia,
• abdominal pain,
• nausea vomiting,
• acetone breath,
• hyperventilation with Kussmaul respirations, and
• mental status changes
 Assessment of DKA

• Blood glucose levels vary from 300–800 mg/dL

• Severity of DKA is not related to blood glucose level
• Ketoacidosis is reflected in low serum bicarbonate and low pH; low PCO2
reflects respiratory compensation
• Ketone bodies in blood and urine
• Electrolytes vary according to water loss and level of hydration
 Prevention

• “Sick day rules”

• Assess for underlying causes
• Diagnosis and proper management of diabetes
 Treatment of DKA

• Rehydration with IV fluid

• IV continuous infusion of regular insulin
• Reverse acidosis and restore 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
• Blood glucose and renal function/UO
• EKG and electrolyte levels—Potassium
• VS, lung assessments, signs of fluid overload
 Hyperglycemic Hyperosmolar Nonketotic
Syndrome/Coma (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.
• 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
• BGSM
• Diagnosis and management of diabetes
• Assess and promote self-care management skills
 Long Term Complication of Diabetes
• Macrovascular complications • Neuropathic changes
• Peripheral neuropathy,
• Accelerated atherosclerotic changes
• autonomic neuropathies,
• Coronary artery disease,
• hypoglycemic unawareness,
• cerebrovascular disease, and • neuropathy,
• peripheral vascular disease • sexual dysfunction

• Microvascular complications
• Diabetic retinopathy,
• nephropathy
 Diabetic Retinopathy

• caused by changes in the small blood vessels in the retina, which is the area
of the eye that receives images and sends information about the images to
the brain
• three main stages:
• nonproliferative (background),
• preproliferative, and
• proliferative.
• Manifestations: usually asymptomatic
• Diagnostic Findings: fluorescein angiography
• Side effects
• nausea during the dye injection;
• yellowish,
• fluorescent discoloration of the skin and urine lasting 12 to 24 hours; and
• occasionally allergic reactions

• Treatment
• Maintenance of Blood glucose to normal level
• argon laser photocoagulation for advance cases
 Nephropathy

• Common complication of diabetes

• More prone to type 1 diabetes (shows at the initial 10-15 yrs of diabetes)
• Clinical manifestation:
• frequent hypoglycemia,
• albumin in urine, HPN
• Assessment and diagnostic Findings:
• urine test – presence of microalbuminuria (>30 mg/24 hours)
• Creatinine and BUN
 Management

• Control of HPN
• Prevention or vigorous treatment of urinary tract infections
• Avoidance of nephrotoxic medications and contrast dye
• Adjustment of medications as kidney function changes
• Low-sodium diet
• Low-protein diet