Diabetes Mellitus
Liver:
Key Players:
Glucose:
 “Sugar” (body needs it to survive)
fuels the cells of your body so they
can work properly, BUT IT CAN
NOT ENTER THE CELL
WITHOUT THE HELP OF INSULIN
 It is stored mainly in the liver in the
form of glycogen
Insulin:
 “deals with high blood sugar levels”
 A hormone that helps regulate the
amount of glucose in the blood (too
much glucose is very toxic to the
body).
 It allows your body to use glucose by
allowing it to enter the cells (without
insulin glucose would just float
around in your body)
 Secreted by the BETA cells of the
pancreas from the islets of
Langerhans
Glucagon:
 “deals with low blood sugar levels”
 A peptide hormone that causes
the liver to turn glycogen into
glucose…does the opposite as
insulin.
 Also secreted by the pancreas
Pancreas:
 Releases insulin and glucagon
 Sensitive to insulin levels and stores
and turns glycogen into glucose when
the pancreas secretes
glucagon. Example: (if the body has
increased blood glucose/increased
insulin in the blood the liver with
absorb and store the extra glucose for
later….if there is low blood sugar/low
insulin levels the liver will release
glycogen which turns into glucose to
help increase the blood sugar level)
Glucagon and Insulin Feedback Loop
1. Increased blood sugar -> pancreas
releases insulin -> causes glucose to
enter into the cells to be used or be
saved as glycogen for later (stored
mainly in the liver)
2. Decrease blood sugar -> pancreas
release glucagon -> causes the liver to
release glycogen which turns into
glucose to increase the low blood
sugar level
What happens in diabetes mellitus?
The body is unable to use glucose due to
either the absence of insulin or the body’s
resistance to use insulin. Therefore, the
patient becomes HYPERGLYCEMIA (the
glucose just hangs out in the blood stream
which affects major organs of the body)
The body starts to metabolize FATS for
energy (since it can’t get to the
glucose…remember glucose can NOT enter
the cell without the help of
INSULIN)….which happens in Type 1
diabetics OR there is a moderate amount of
insulin to deal with fats and proteins BUT
carbs cannot be used (Type 2).
Causes of Diabetes Mellitus
Divided into types:
Type 1: the beta cells located in the islet of
Langerhans don’t work (been destroyed)
therefore the body doesn’t release anymore
insulin. For treatment, the patient MUST
USE INSULIN.
Risk factors: Genetic, auto-immune (virus)
NOT RELATED TO LIFESTYLE (like type
2)
What do patients look like clinically? Patients
are young and thin….happens suddenly;
ketones will be present in the urine
Type 2: cells quit responding to insulin
(won’t let insulin do its job by taking the
glucose into the cell). Therefore, the patient
has INSULIN RESISTANCE. This leaves all
the glucose floating around in the blood and
the pancreas senses there’s a lot of glucose
present in the blood so it releases even more
insulin. Due to this the patient starts to
experience hyperinsulinemia which caused
metabolic syndrome
Treatment: diet and exercise (first line
treatment)…when that doesn’t work oral
medications are started Note: The type 2
diabetic may NEED INSULIN DURING
STRESS, SURGERY, OR INFECTION
Risk Factors: Lifestyle- being obese,
sedentary, poor diet (sugary drinks), stress
AND genetic
What do patients look like clinically? Patients
are overweight, it happens overtime, rare to
have ketones (remember issues with carb
metabolism) adult aged
Gestational: similar to type 2 diabetes where
the cells are not receptive to
insulin…typically goes away after birth
Complications of Diabetes Mellitus
Hypoglycemia:
 Blood glucose less than 60 mg/dL or
drops rapidly from an elevated level.
 Remember the mnemonic: “I’m
sweaty, cold, and clammy….give me
some candy”
 Signs and Symptoms: Sweating,
clammy, confusion, light headedness,
double vision, tremors
 Treatment: Need simple carbs if they
can eat, or if unconscious IV D50
 Simple carbs include: hard candies,
fruit juice, graham crackers, honey
Organ Problems:
Hardens the vessel (atherosclerotic….makes
vessels hard from all the glucose that sticks
on the proteins of the vessels and it forms
plaques). So the patient can develop heart
disease, strokes, hypertension, neuropathy,
poor wound healing (FROM DECREASE
circulation), eye trouble, infection.
1. DKA (Diabetic Ketoacidosis):
 Happens in Type 1 diabetics (rare to
happen in type 2)
 There is no insulin in the body and the
body starts to burn fats for energy
since it can’t get to the glucose
  Due to this the ketones, which are
acids, start to enter into the body and
this causes life-threatening situation,
such as acid/base imbalances
 Signs and Symptoms of DKA: N&V,
excessive thirst, hyperglycemia,
Kussmaul breathing
2. Polydipsia: very thirsty
Why? the blood is trying to prevent the body
from becoming dehydrated from the
excessive urination so it signals to the patient
to drink more water…but it doesn’t work
because the kidneys will remove the excess
water

2. HHNS Hyperglycemic hyperosmolar 3. Polyphagia: very hunger

nonketotic syndrome:
Why? the body is burning FAT for energy
 Happens mainly in Type 2 diabetics since it doesn’t have any glucose to use so the
body signals to the person to keep eating so
 This presents with hyperglycemia
there will be food to use for energy. The
without the breakdown of
patient will have WEIGHTLOSS!
ketones…so there isn’t
acidosis/ketosis because there is just
enough insulin present in the body to
*The 3 P’s present mainly in Type 1
prevent the breakdown of fats
Diabetics
 Signs and Symptoms of HHNS: very
dehydrated, thirsty, hyperglycemic,
mental status changes Other Assessment findings of the Diabetic
Patient
Remember “Sugar”
Assessment Findings of DM
 Slow wound healing
3 of Hyperglycemia P’s & SUGAR
 blUrry vision (damaged from glucose
Hyperglycemia: Three P’s on eyes)
1. Polyuria: (frequent urination)  Glycosuria (kidneys can’t reabsorb all
the extra glucose)
Why? elevated levels of glucose in the body  Acetone smell of breath (from
causes the body to remove the water from burning ketones) *type 1
inside the cell (remember in the hypertonic,  Rashes on skin DRY and itchy,
hypotonic video about OSMOSIS). The repeated vaginal infections
water will move to an area of higher (yeast….loves glucose)
concentration which will be the blood stream
and this causes more fluid to enter the blood
stream. The kidneys will secrete the extra
water. HOWEVER, normally your kidneys
could handle all of the glucose by
reabsorption but there is too much so it leaks
into the urine…. GLYCOSURIA
Diabetes Nursing Management
Nurse’s role: educating, monitoring, and
administering (medications)
Teach patient to follow the Triangle of
Diabetes Management
**Diet, medications, and exercise all work
together while monitoring blood glucose
Example: Patient wants to make sure their
diet is balanced with their medication
(insulin/oral meds) and they use exercise to
manage glucose levels (doing all this while
monitoring blood glucose).
As the nurse you will be educating the
diabetic…so for the NCLEX know education
pieces like:
 Diet, exercising, oral medications,
giving insulin (peak times), drugs that
increase blood glucose and lower
glucose etc.
Diabetic Diets
DIET: Diets are individualized due to
physical activity and medication therapy
(they always need tweaking)…recommend
following American Diabetic Association
Diet (ADA)
Limitation of the following:
 Carbs (45-60%) grains, vegetables
with starches potatoes, corn,
sweets…cookies, soda, dried beans,
milk)
 Fats (<20 %)….limit unhealthy fats
saturated, trans fats, cholesterol: lard,
gravies, whole milk, bologna, hot
dogs, sausage, processed foods
hydrogenated oils…concentrate on
mono & polyunsaturated avocadoes,
olives, peanuts, nuts
 Proteins (15-20%) meats don’t
increase the glycemic index: meats
chicken, turkey, fish, plant based
beans, peas, low fat cheese, eggs
whites
Exercising Management
Exercise: Aerobic the best (helps the body
use insulin) ex: cardio running, walking,
swimming etc.
Teach patient signs of hypoglycemia &
hyperglycemia
Signs of Hypoglycemia:
 “I’m sweaty, cold, and
clammy….give me some candy”
 “Sweating, clammy,
confusion, light headedness,
double vision, tremors”
Signs of Hyperglycemia: Three P’s
 Polyphagia
 I’m hot and dry…I must be on
a sugar high!
  Polydipsia
 Polyuria
 Always check blood sugar prior to
exercising: if lower than 100 eat a
small carb snack and carry SIMPLE
carbs with you while exercising in
case of hypoglycemic attack
 Example of simple
carbs: hard candy, honey,
crackers/graham crackers,
fruit juice
****If patient plans on exercising for an
extended period of time, check glucose prior,
during, and after.
****If blood glucose is higher than 250 with
ketones present in urine prior to exercise
avoid exercise until glucose and ketones
stabilize.
Diabetic Medications
NCLEX specific:
Oral medications (for patients with Type 2
diabetes when exercise and diet doesn’t work
to control blood glucose):
 Sulfonylureas: ides zides, mides,
rides” (most common) stimulate beta
cells in pancreas to make
insulin (Glyburide, Glipizide,
Diabinese, Amaryl) AVOID
ETOH….extreme hypoglycemia
 Meglitinides: “glinide” Ex:
repaglinide “Prandin” stimulate beta
cells in pancreas to make
insulin…instruct pts to take first bite
with meal
 Biguanides: Metformin
(Glucophage)….causes the liver to
decrease its stores of glucose. Watch
out if patient is scheduled for
surgery/procedure (heart cath)…stop
for 48 hours and watch renal
function…diarrhea
 Alpha-glucoside inhibitors: Precose,
Glyset lower blood sugar by slowly
down the breakdown of starchy foods
in the GI system which helps slowly
rise the blood sugar… instruct pts to
take first bite with meal
 Thiazolidinedione: “glitazone”
reduce glucose production in the
liver: Actos/Avandia watch liver
function and heart function increase
risk of MIs
Medications that cause hypoglycemia
 Remember from the hypertension
lecture that Beta Blockers (mask
symptoms of hypoglycemia)
 Other medication that cause it:
ETOH, ASA, Sulfonylureas
(medications used to treat type 2:
Glyburide, Glipizide, Diabinese), and
MAO inhibitors (meds for
depression) , Bactrim (common
antibiotic)
Medications that cause hypergycemia
Thiazide diuretics (HCTZ), Glucocorticoids
(Prednisone, Hydrocortisone), estrogen
therapy
Insulin 1. Rapid-Acting Insulin:
It is used for Type 1 regularly, and sometimes “15 minutes feels like
for Type 2 diabetics if the patient is an hour during 3 rapid responses.”
experiencing stress on the body like surgery
 Onset: 15 minutes
or illness.
 Peak: 1 hour
Know the categories of insulin. Example:
whether they are rapid, short, intermediate,  Duration: 3
long acting and the onset, peak, and duration.
Note: Peak is the most susceptible time for

2. Short-Acting Insulin:
“Short-staffed nurses went from 30 patient to
(2) 8 patients.”
 Onset: 30 minutes
 Peak: 2 hours
 Duration: 8 hours

3. Intermediate-Acting Insulin:
“Nurses Play Hero to (2) eight 16 year olds.”
 Onset: 2 hours
 Peak: 8 hours
 Duration: 16 hours

hypoglycemia 4. Long-Acting Insulin:

“The two long nursing shifts never
Insulin Mnemonics peaked but lasted 24 hours.”

Note that if you use the word insulin you can  Onset: 2 hours
divide the word and separate it into specific  Peak: NONE
categories of insulin types. Watch the lecture
above for a full in-depth explanation about  Duration: 24 hours
this mnemonic.

Key Points to Remember about

Administering Insulin
  Rotate sites: do not use the same site
more than once in a 2-3 week period
this PREVENTS
LIPODYSTROPHY (pitting of subq
fat)
 Sites include: abdomen, arms,
and thighs
 When mixing insulin (clear to cloudy)
clean=regular, cloudy=NPH
 Don’t massage site after
administration increase
hypoglycemia due to absorption

Dawn Phenomenon:
Watch for Dawn phenomenon (hence the
name dawn…crack of dawn means the
waking hours) this is a time when the body
will increase the blood sugar in preparation
for waking. However, when you have insulin
problems (not enough of it) the increased
blood sugar causes HYPERGLYCEMIA
Typical time: 5am to 8 am
Treatment: may need a night time dose of
NPH to counteract.

Somogyi Effect:
Somogyi effect (remember S in Somogyi for
sleeping hours): This is a drop in blood sugar
at the hours of 2 to 3 am. This happens when
the body releases hormones such as coristol,
catecholamines, growth hormones to increase
the blood sugar. However, in diabetics the
body can’t cope with the increased blood
sugar and the sugar will be elevated.
Treatment: Eat a bedtime snack….a dose of
bedtime insulin will prevent it from dropping
so low or decreasing insulin amounts at night