Complications of DM • usually absorbs faster

• can cause bruising at the site of insulin

Insulin administration
delivery.
1. Subcutaneous injections and mixing insulin
6. Pancreas transplant
• it must be injected SQ because it is a
• the goal of pancreatic transplantation is
protein that is destroyed in the digestive
to halt or reverse the complications of
tract if taken orally.
DM.
• it is standardized in units for SQ
• transplantations are performed on a
administration.
limited number of clients (generally,
2. Insulin pumps these are clients who are undergoing
kidney transplantation simultaneously)
• continuous SQ insulin infusion is
• Immunosuppressive therapy is
administered by an externally worn
prescribed to prevent and treat
device that contains a syringe attached
rejection.
to a long , thin, narrow-lumen tube with
a needle or Teflon catheter to the end. Self-monitoring of blood glucose level
• the client inserts the needle or Teflon
• Self-monitoring provides the client with
catheter into the SQ tissue (usually on
the current blood glucose level and
the abdomen) and secures it with tape
information to maintain good glycemic
or a transparent dressing.
control
• the pump is worn on a belt or in a
• Monitoring requires a finger prick to
pocket.
obtain a drop of blood for testing
• the needle or Teflon catheter is changed
• Alternative site testing (obtaining blood
at least every 2 to 3 days.
from the forearm, upper arm,
• both rapid-acting and regular insulin
abdomen, thigh, or calf) is now
(buffered to prevent the precipitation of
available using specific measurement
insulin crystals within the catheter) are
devices.
appropriate for use in these pumps.
• Tests must be used with caution in
3. Insulin pumps and a skin sensor clients with diabetic neuropathy.

• a skin sensor device that monitors the Client instruction:

client’s blood glucose continuously.
• Use the proper procedure for obtaining
• the information is transmitted to the
the sample for determining the blood
pump, determines the need for insulin,
glucose level
and then the insulin is injected.
• Perform the procedure precisely to
• the pump holds up to a 3-day supply of
obtain accurate results
insulin and can be easily disconnected
• Follow the manufacturer’s instructions
for activities such as bathing.
for the glucometer
4. Jet injectors • Wash hands before and after
performing the procedure to prevent
• is a needleless device that delivers
infection
insulin through the skin under pressure
in an extremely fine stream.
 • Calibrate the monitor as instructed by
the manufacturer
• Check the expiration date on the test
strips
• Is the blood glucose level results do not
seem reasonable, reread instructions,
reassess technique, check the expiration
date of the test strips, and perform the
procedure again to verify results.
Urine testing
• Urine testing for glucose is not a reliable
indicator of the blood glucose level and
is not used for monitoring purposes
• instruct the client in the procedure for
testing for urine ketones
• the presence of ketones may indicate
impending ketoacidosis
• urine ketone testing should be
performed during illness and whenever
the client with type 1 Dm has
persistently elevated blood glucose
levels (higher than 240 mg/dL for two
consecutive testing periods)
Complications of Insulin Therapy
1. Local allergic reactions
• Redness
• Swelling
• Tenderness
• Induration or a wheal at the site if
injection – 1 to 2 hours after
administration
• Reactions usually occurs during the
early stage of insulin therapy.
• Instruct the client to cleanse the skin
with alcohol before injection.
2. Insulin Lipodysthropy
• Lipoatrophy - is a loss of subcutaneous
fat and appears as slight dimpling or
more serious pitting of SQ fat
• the use of human insulin helps prevent
this complication
• Lipohypertrophy – is the development
of fibrous fatty masses at the injection
site
• is caused by repeated use of an
injection site
Nursing management:
• instruct the client to avoid injecting
insulin into affected sites
• instruct the client about the importance
of rotating insulin injection at one
anatomical site
3. Insulin resistance
• is also the term used for lack of tissue
sensitivity to the insulin from the body,
which results in hyperglycemia.
Treatment:
• administering a purer insulin
preparation
4. Dawn Phenomenon
• results from reduced tissue sensitivity
to insulin that usually develops between
5 and 8 am (prebreakfast hyperglycemia
occurs)
• it may be caused by nocturnal release of
growth hormone.
Treatment:
• administering an evening dose (or
increasing the amount of a current
dose) of intermediate-acting insulin at
about 10 pm.
5. Somogyi phenomenon
• normal or elevated blood glucose levels
are present at bedtime
• hypoglycemia occurs at about 2 to 3 am,
which causes an increase in the
 production of counterregulatory The second group of signs is related to the
hormones. hypoglycemic state stimulating the sympathetic
• by about 7 am, in response to the nervous system (SNS).
counterregulatory hormones, the blood
• Increased pulse
glucose rebounds significantly to the
• Pale moist skin
hyperglycemic range.
• Anxiety
Treatment: • Tremors
• decreasing the evening (predinner or If untreated , loss of consciousness, seizure and
bedtime) dose of intermediate-acting death will result.
insulin or increasing the bedtime snack.
A. Mild hypoglycemia
Acute complications of DM
• the client remains fully awake but
Hypoglycemia (Insulin Shock) displays adrenergic symptoms.
• blood glucose level: lower than 60
• occurs when the blood glucose level
mg/dL.
falls below 70 mg/dL or when the blood
• Hunger
glucose level drops rapidly from an
elevated level. • Nervousness
• it usually occurs in Type 1 DM, following • Palpitations
strenuous exercise, an error in dosage, • Sweating
vomiting, or skipping a meal after • Tachycardia
insulin administration. • Tremor
• The lack of glucose quickly affects the Interventions:
nervous system – because neurons
cannot use fats or proteins as an energy • Give 10 to 15 g of a fast-acting simple
source. carbohydrates
• It can be life-threatening or can cause • Retest the blood sugar level in 15 mins,
brain damage if it is not treated and repeat the treatment of symptoms
promptly. do not resolve, a snack containing
protein and carbohydrates is
Assessment: recommended unless the client plans to
One group of signs is related to impaired eat a regular meal within 60 mins.
neurologic function resulting from the lack of B. Moderate hypoglycemia
glucose.
• the client displays symptoms of
• Poor concentration worsening hypoglycemia.
• Slurred speech • blood glucose level: lower than 40
• Lack of coordination mg/dL.
• Staggering gait • Confusion
They are sometimes assumed to be intoxicated • Double vision
with alcohol. • Drowsiness
• Emotional changes
• Headache
Interventions:
• Administer 15 to 30 g of a fast-acting
simple carbohydrate.
• Administer additional food after 10 to
15 mins such as low-fat milk, cheese,
and crackers.
C. Severe hypoglycemia
• the client displays severe
neuroglycopenic symptoms.
• blood sugar level: lower than 20 mg/dL
• Difficulty arousing
• Disoriented behavior
• Loss of consciousness
• Seizure
Interventions:
• If the client is unconscious and cannot
swallow, an injection of glucagon is
administered SQ or IM.
• Administer a second dose in 10 mins. if
the client remains unconscious.
• Give nothing my mouth.
• A small meal is given to the client when
the client awakens as long as the client
is not nauseated.
• The physician is notified if a severe
hypoglycemic reaction occurs.
• Family members need to be instructed
about the administration of glucagon.
DO NOT attempt to administer oral food or
fluids to the client experiencing a severe
hypoglycemic reaction who is semiconscious or
unconscious and is unable to swallow. (RISK
FOR ASPIRATION!)
In hospital setting:
• the client may be treated with an IV
injection of 25-50 mL of 50% dextrose in
water (D50W) – bolus.
Diabetic Ketoacidosis (DKA)
• is a life-threatening complication of
Type 1 DM that develops when severe
insulin deficiency occurs.
• the main clinical manifestations include:
• hyperglycemia
• dehydration
• ketosis
• acidosis
• It is more common in Type 1 DM
patients.
• It may also result from an error in
dosage or overindulgence in food or
alcohol.
Manifestations
Ketosis
• Kussmaul’s respiration – rapid and deep
– compensation
• “acetone” breath- fruity, sweet smell –
acetone expired
• Nausea - results from electrolyte
imbalances of Na, K, Ch
• Abdominal pain - results from
electrolyte imbalances of Na, K, Ch
Dehydration or electrolyte loss
• Polyuria - osmotic diuresis due to
glucosuria
• Polydipsia - response to water loss
• Weight loss - loss of fluid and lack of
glucose to cells
• Dry skin - decreased interstitial fluid
• Sunken eyes - decreased interstitial fluid
• Lethargy - indicates depression of the
CNS owing to acidosis and decreased
blood flow
• Coma - indicates depression of the CNS
owing to acidosis and decreased blood
flow
 • Oliguria (decreased UO) – indicates that • Insulin is infused continuously until SQ
compensation mechanisms to conserve administration resumes to prevent a
fluid in the body are taking place. rebound of the blood glucose level.
• Monitor vital signs
Note: DKA and hypoglycemia both causes loss
• Monitor urinary output and for signs of
of consciousness. The Emergency treatment for
fluid overload
DKA is insulin, fluid, ad sodium bicarbonate.
• Monitor potassium and glucose levels
Assessment should differentiate the cause.
and for signs of increased intracranial
Interventions: pressure.
• The potassium level will fall rapidly
• Restore circulating blood volume and
within the first hour of treatment as the
protect against cerebral, coronary, and
dehydration and the acidosis are
renal hypoperfusion.
treated
• Treat dehydration with rapid IV
• Potassium is administered IV in a
infusions of 0.9% or 0.45% normal
diluted solution as prescribed when the
saline (NS) as prescribed
potassium reaches normal level to
• Dextrose is added to IV fluids (D5NS, or
prevent hypokalemia.
5% dextrose in 0.45% saline) when the
• Ensure adequate renal function before
blood glucose level reaches 250 to 300
administering potassium.
mg/dL
• Monitor the client being treated for DKA
• Treat hyperglycemia with regular insulin
closely for signs of increased intracranial
administered intravenously as
pressure.
prescribed.
• If the blood glucose level falls too far or
Regular insulin is the ONLY insulin that can be too fast before the brain has time to
administered IV. Used in emergency treatment equilibrate, water is pulled from the
for DKA blood to the cerebrospinal fluid and the
brain, causing cerebral edema and
Insulin IV administration
increased ICP.
• Use regular insulin only Client education:
• An IV bolus dose of regular insulin
(usually 5 to 10 units) may be Guidelines during illness
prescribed before a continuous infusion
• Take insulin or oral antidiabetic
is begun).
medications as prescribed
• Mix the prescribed IV dose of regular
• Test blood glucose level and test the
insulin for continuous infusion with 0.9
urine for ketones every 3 to 4 hours
% or 0.45% NS as prescribed.
• If the usual meal plan cannot be
• Flush insulin solution through the entire
followed, substitute soft foods six to
IV infusion set and discard the first 50 to
eight times a day.
100 mL of solution before connecting
and administering it to the client Hyperglycemic hyperosmolar non-ketotic
(insulin molecules adhere to the plastic syndrome (HHNS)
of IV infusion sets)
• life-threatening complication
• Always place the insulin infusion on an
IV infusion controller.
 • extreme hyperglycemia occurs without because ketosis and acidosis do not
ketosis or acidosis occur.

Hyper osmolarity – because there’s a very Chronic complications of DM

concentrated blood due to high blood glucose in
Microangiopathy
the body.
• where the capillary basement
• The syndrome occurs more often in
membrane becomes thick and hard,
individuals with Type 2 DM
causes obstruction or rupture of
• Often the patient is an older person
capillaries and small arteries and results
with infection or one who has
in tissue necrosis and loss of function
overindulged in carbohydrates, thereby
using more insulin than anticipated. Diabetic Retinopathy
• In these case, hyperglycemia and
• chronic and progressive impairment of
dehydration develop because of the
the retinal circulation that eventually
relative insulin deficit, but sufficient
causes hemorrhage
insulin is available to prevent
• permanent vision changes and leading
ketoacidosis.
cause of blindness
The Major Difference
Assessment:
• The major difference between HHNS
• A change in vision – is caused by the
and DKA is that ketosis and acidosis do
rupture of small microneurysms in the
not occur with HHNS; enough insulin is
retinal blood vessels
present with HHNS to prevent
breakdown of fats for energy, thus • Blurred vision – results from macula
preventing ketosis. edema
• Sudden loss of vision – results from
Manifestations: retinal detachment.
• Cataracts – results from lens opacity
• Altered central nervous system function
with neurologic symptoms Interventions:
• Dehydration or electrolyte loss: same as
DKA • Maintain safety
• Photocoagulation (laser therapy) may
Interventions: be done to remove hemorrhagic tissue
to decrease scarring and prevent
• Treatments is similar to that for DKA,
progression of the disease process
includes:
• Vitrectomy may be done to remove
• Fluid replacement – in older adult client
vitreous hemorrhages and thus
must be done very carefully because of
decrease tension on the retina,
the potential of heart failure.
preventing detachment
• Correction of electrolyte imbalances
• Cataract removal with lens implantation
• Insulin administration – insulin plays a
improve vision
less critical role in treatment of HHNS
that it does for the treatment of DKA
Diabetic nephropathy • involves a single nerve or group of
nerves, most frequently cranial nerves
• vascular degeneration in the kidney
III (oculomotor) and VI (abducens),
glomeruli, eventually leading to chronic
resulting in diplopia
renal failure.
• is responsible for 40% of patients in Sensory or peripheral neuropathy
end-stage renal failure.
• affects distal portions of nerves, most
Assessment: frequently in the lower extremities

• Microalbuminuria Autonomic neuropathy

• Thirsts
• symptoms vary according to organ
• Fatigue
system involved
• Anemia
• Weight loss Cardiovascular

Interventions: • cardiac denervation syndrome (heart

rate does not respond to changes in
• Assess vital signs
oxygenation needs)
• Monitor intake and output
• orthostatic hypotension occurs
• Monitor the Blood urea nitrogen (BUN)
and creatinine and urine albumin (BUA) Pupillary
levels
• pupils does not dilate in response to
• Restrict dietary protein, sodium, and
decreased light
potassium intake as prescribed
• Avoid nephrotoxic medications Gastric

Macroangopathy • decreased gastric emptying

(gastroparesis)
• affects the large arteries, thus leading to
a high incidence of heart attacks, Urinary
strokes, and peripheral vascular disease
• neurogenic bladder
in diabetes.
Sudomotor
Diabetic neuropathy
• decreased sweating
• General deterioration of the nervous
system throughout the body. Adrenal
• Complications include:
• hypoglycemic unawareness
• development of non-healing ulcers of
the feet Reproductive
• gastric paresis
• erectile dysfunction • impotence (male), painful intercourse
(female)
Classifications:
Assessment:
Focal neuropathy or mononeuropathy
• Paresthesia
• Decreased or absent reflexes
 • Poor peripheral pulses • Cut toenails straight across and smooth
• Nausea and vomiting nails with an emery board
• Diarrhea or constipation • Avoid smoking

Interventions: Infections

• Careful foot care is required to prevent
trauma
• Administer medications as prescribed
for pain relief
• Initiate bladder training programs
Preventive foot care instructions
• Provide meticulous skin care and proper
foot care
• Inspect feet daily and monitor feet for
redness, swelling, or break in skin
integrity
• Avoid thermal injuries from hot water,
heating pads and baths
- Wash feet with warm (not hot) water and dry
thoroughly (avoid foot soaks)
• Avoid treating corns, blisters, or
ingrown toenails
• Apply moisturizing lotion to the feet but
not between the toes
• are more common and tend to be more
severe in diabetic – because of vascular
impairment, which decreases tissue
resistance.
• delay in healing because of insulin
deficit, and the increased glucose levels
in the body fluids that supports
infection
Susceptible for:
• Tuberculosis
• Fungal infections – Candida
• UTI – if bladder function is
compromised which predisposes to
cystitis and pyelonephritis
• Periodontal disease (infection in the
tissue around the teeth)
• Dental caries

- Prevent moisture from accumulating between

toes.

• Wear loose socks and well-fitting (not

tight) shoes, and instruct client not to
go barefoot

- Wear clean cotton socks to keep the feet warm

and change the socks daily.

• Avoid wearing the same pair of shoes 2

days in a row.

- Avoid wearing open-toe or shoes with strap

that goes between the toes.

- Check shoes for cracks or tears in the lining

and for foreign objects before putting them on.

- Break in new shoes gradually