INTRODUCTION

INTRODUCTION
Diabetes Mellitus
Diabetes mellitus (sometimes called "sugar diabetes") is a condition that occurs when the
body can't use glucose (a type of sugar) normally. Glucose is the main source of energy
for the body's cells. The levels of glucose in the blood are controlled by a hormone called
insulin, which is made by the pancreas. Insulin helps glucose enter the cells.
In diabetes, the pancreas does not make enough insulin (type 1 diabetes) or the body can't
respond normally to the insulin that is made (type 2 diabetes). This causes glucose levels
in the blood to rise, leading to symptoms such as increased urination, extreme thirst, and
unexplained weight loss.
The honeymoon period for patients with Diabetes mellitus type 1 is the period that often
follows diagnosis and initiation of insulin treatment. It is often suggestive of remission,
but it is important to note that the two are unrelated - it is not a cure for type 1 diabetes.
During this period some of the insulin-producing beta cells of the pancreas have not been
completely destroyed yet and produce unpredictable amounts of endogenous insulin. This
period does not occur in all patients. If the honeymoon period does occur, it lasts for
varying lengths of time and can affect diabetics differently.
The islets of Langerhans are destroyed in type I diabetes mellitus. This occurs probably
as a consequence of a genetic susceptibility, followed by the onset of autoimmune
destruction triggered by some environmental factor such as a viral infection. Heavy
lymphocytic infiltrates appear in and around islets. The number and size of islets are
eventually reduced, leading to decreased insulin production and glucose intolerance.
The islets of Langerhans are normal in number or somewhat reduced with type II diabetes
mellitus. Fibrosis and deposition of amylin polypeptide within islets are most
characteristic of the chronic states of type II diabetes.

DEFINITION

DEFINITION
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia
resulting from defects in insulin secretion, insulin action, or both. The chronic
hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure
of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.
OR
Diabetes mellitus is a variable disorder of carbohydrate metabolism caused by a
combination of hereditary and environmental factors and usually characterized by
inadequate secretion or utilization of insulin, by excessive urine production, by excessive
amounts of sugar in the blood and urine, and by thirst, hunger, and loss of weight.

Definition of TYPE 1 DIABETES

Diabetes of a form that usually develops during childhood or adolescence and is
characterized by a severe deficiency of insulin secretion resulting from atrophy of the
islets of Langerhans and causing hyperglycemia and a marked tendency toward
ketoacidosiscalled

also insulin-dependent

diabetes,

insulin-dependent

diabetes

mellitus, juvenile diabetes, juvenile-onset diabetes, type 1 diabetes mellitus.

Definition of TYPE 2 DIABETES
Diabetes mellitus of a common form that develops especially in adults and most often in
obese individuals and that is characterized by hyperglycemia resulting from impaired
insulin utilization coupled with the body's inability to compensate with increased insulin
productioncalled also adult-onset diabetes, late-onset diabetes, maturity-onset diabetes,
non-insulin-dependent diabetes, non-insulin-dependent diabetes mellitus, type 2 diabetes
mellitus.

TYPES OF DIABETES

TYPES OF DIABETES

There are three main types of diabetes:

Type 1 diabetes is an auto-immune disease where the body's immune system attacks the
insulin-producing cells of the pancreas. People with type 1 diabetes cannot produce insulin and
require lifelong insulin injections for survival. The disease can occur at any age, although it
mostly occurs in children and young adults. Type 1 diabetes is sometimes referred to as 'juvenile
onset diabetes' or 'insulin dependent diabetes'.

Type 2 diabetes is associated with hereditary factors and lifestyle risk factors including
poor diet, insufficient physical activity and being overweight or obese. People with type 2
diabetes may be able to manage their condition through lifestyle changes; however, diabetes
medications or insulin injections may also be required to control blood sugar levels. Type 2
diabetes occurs mostly in people aged over 40 years old; however, the disease is also becoming
increasingly prevalent in younger age groups.

Gestational diabetes occurs during pregnancy. The condition usually disappears once the
baby is born; however, a history of gestational diabetes increases a woman's risk of developing
type 2 diabetes later in life. The condition may be managed through adopting healthy dietary and
exercise habits, although diabetes medication, including insulin, may also be required to manage
blood sugar levels.

Type 1 Diabetes
Type 1 diabetes is also called insulin-dependent diabetes. It used to be called juvenileonset diabetes, because it often begins in childhood.Type 1 diabetes is an autoimmune
condition. It's caused by the body attacking its own pancreas with antibodies. In people
with type 1 diabetes, the damaged pancreas doesn't make insulin.
This type of diabetes may be caused by a genetic predisposition. It could also be the
result of faulty beta cells in the pancreas that normally produce insulin.
A number of medical risks are associated with type 1 diabetes. Many of them stem from
damage to the tiny blood vessels in your eyes (called diabetic retinopathy), nerves
(diabetic neuropathy), and kidneys (diabetic nephropathy). Even more serious is the
increased risk of heart disease and stroke.
Treatment for type 1 diabetes involves taking insulin, which needs to be injected through
the skin into the fatty tissue below. The methods of injecting insulin include:

Syringes

Insulin pens that use pre-filled cartridges and a fine needle

Jet injectors that use high pressure air to send a spray of insulin through the skin

Insulin pumps that dispense insulin through flexible tubing to a catheter under the skin of
the abdomen
A periodic test called the A1C blood test estimates glucose levels in your blood over the
previous three months. It's used to help identify overall glucose level control and the risk
of complications from diabetes, including organ damage.
Having type 1 diabetes does require significant lifestyle changes that include:
Frequent testing of your blood sugar levels

Careful meal planning

Daily exercise

Type 1 Diabetes

Type 2 Diabetes
By far, the most common form of diabetes is type 2 diabetes, accounting for 95% of
diabetes cases in adults. Some 26 million American adults have been diagnosed with the
disease. Type 2 diabetes used to be called adult-onset diabetes, but with the epidemic of
obese and overweight kids, more teenagers are now developing type 2 diabetes. Type 2
diabetes was also called non-insulin-dependent diabetes.
Type 2 diabetes is often a milder form of diabetes than type 1. Nevertheless, type 2
diabetes can still cause major health complications, particularly in the smallest blood
vessels in the body that nourish the kidneys, nerves, and eyes. Type 2 diabetes also
increases your risk of heart disease and stroke.
With Type 2 diabetes, the pancreas usually produces some insulin. But
either the amount produced is not enough for the body's needs, or the body's cells are
resistant to it. Insulin resistance, or lack of sensitivity to insulin, happens primarily in fat,
liver, and muscle cells.
People who are obese -- more than 20% over their ideal body weight for their height -are at particularly high risk of developing type 2 diabetes and its related medical
problems. Obese people have insulin resistance. With insulin resistance, the pancreas has
to work overly hard to produce more insulin. But even then, there is not enough insulin to
keep sugars normal.
There is no cure for diabetes. Type 2 diabetes can, however, be controlled withweight
management, nutrition, and exercise. Unfortunately, type 2 diabetes tends to progress,
and diabetes medications are often needed.
An A1C test is a blood test that estimates average glucose levels in your blood over the
previous three months. Periodic A1C testing may be advised to see how well diet,

exercise, and medications are working to control blood sugar and prevent organ damage.
The A1C test is typically done a few times a year.

Type 2 Diabetes

Gestational Diabetes
Diabetes that's triggered by pregnancy is called gestational diabetes (pregnancy, to some
degree, leads to insulin resistance). It is often diagnosed in middle or late pregnancy.
Because high blood sugar levels in a mother are circulated through the placenta to the
baby, gestational diabetes must be controlled to protect the baby's growth and
development.
According to the National Institutes of Health, the reported rate of gestational diabetes is
between 2% to 10% of pregnancies. Gestational diabetes usually resolves itself after
pregnancy. Having gestational diabetes does, however, put mothers at risk for developing
type 2 diabetes later in life. Up to 10% of women with gestational diabetes develop type
2 diabetes. It can occur anywhere from a few weeks after delivery to months or years
later.
With gestational diabetes, risks to the unborn baby are even greater than risks to the
mother. Risks to the baby include abnormal weight gain before birth, breathing problems
at birth, and higher obesity and diabetes risk later in life. Risks to the mother include
needing a cesarean section due to an overly large baby, as well as damage to heart,
kidney, nerves, and eye.
Treatment during pregnancy includes working closely with your health care team and:

Careful meal planning to ensure adequate pregnancy nutrients without excess fat and
calories

Daily exercise

Controlling pregnancy weight gain

Taking diabetes insulin to control blood sugar levels if needed

GESTATIONAL DIABETES

CAUSES

CAUSES
Genetic Susceptibility
Heredity plays an important part in determining who is likely to develop type 1 diabetes.
Genes are passed down from biological parent to child. Genes carry instructions for
making proteins that are needed for the bodys cells to function. Many genes, as well as

interactions among genes, are thought to influence susceptibility to and protection from
type 1 diabetes.

Autoimmune Destruction of Beta Cells

In type 1 diabetes, white blood cells called T cells attack and destroy beta cells. The
process begins well before diabetes symptoms appear and continues after diagnosis.
Often, type 1 diabetes is not diagnosed until most beta cells have already been destroyed.
At this point, a person needs daily insulin treatment to survive.

Environmental Factors
Environmental factors, such as foods, viruses, and toxins, may play a role in the
development of type 1 diabetes, but the exact nature of their role has not been
determined. Some theories suggest that environmental factors trigger the autoimmune
destruction of beta cells in people with a genetic susceptibility to diabetes. Other theories
suggest that environmental factors play an ongoing role in diabetes, even after diagnosis.

Viruses and infections. A virus cannot cause diabetes on its own, but people are
sometimes diagnosed with type 1 diabetes during or after a viral infection, suggesting a
link between the two. Also, the onset of type 1 diabetes occurs more frequently during the
winter when viral infections are more common. Viruses possibly associated with type 1
diabetes include coxsackievirus B, cytomegalovirus, adenovirus, rubella, and mumps.

Infant feeding practices. Some studies have suggested that dietary factors may raise or
lower the risk of developing type 1 diabetes. For example, breastfed infants and infants

receiving vitamin D supplements may have a reduced risk of developing type 1 diabetes,
while early exposure to cows milk and cereal proteins may increase risk. More research
is needed to clarify how infant nutrition affects the risk for type 1 diabetes.

Insulin Resistance
Insulin resistance is a common condition in people who are overweight or obese, have
excess abdominal fat, and are not physically active. Muscle, fat, and liver cells stop
responding properly to insulin, forcing the pancreas to compensate by producing extra
insulin. As long as beta cells are able to produce enough insulin, blood glucose levels stay
in the normal range. But when insulin production falters because of beta cell dysfunction,
glucose levels rise, leading to prediabetes or diabetes.

Abnormal Glucose Production by the Liver

In some people with diabetes, an abnormal increase in glucose production by the liver
also contributes to high blood glucose levels. Normally, the pancreas releases the
hormone glucagon when blood glucose and insulin levels are low. Glucagon stimulates
the liver to produce glucose and release it into the bloodstream. But when blood glucose
and insulin levels are high after a meal, glucagon levels drop, and the liver stores excess
glucose for later, when it is needed. For reasons not completely understood, in many
people with diabetes, glucagon levels stay higher than needed. High glucagon levels
cause the liver to produce unneeded glucose, which contributes to high blood glucose
levels.

SIGN & SYMPTOMS

Symptoms for type 1 diabetes may occur suddenly and include:

excessive thirst
frequent urination including bedwetting
excessive hunger
unexplained weakness and fatigue
weight loss
blurred vision
vaginal discharge or itch in young girls
nausea and vomiting.

The symptoms of type 2 diabetes have a gradual onset. They can be easily missed
or mistaken as part of the normal ageing process. They include:
blurred vision
tiredness
urinating more frequently
feeling thirsty all the time
numbness and tingling in the feet or legs
recurrent infections.

SYMPTOMS OF DIABETES
MELLITUS

 Increased Thirst and Urination

Two symptoms that occur in many people with the disease are increased thirst and frequent
urination. Increased levels of glucose in blood leads to increase excretion of glucose by the
kidneys.Glucose will take more and more water with it, so a diabetic patient will suffer
frequent urination which will in turn lead to increased thirst. To quench your thirst, you
drink a lot of water and other beverages, and that leads to more frequent urination.

 Extreme hunger, fatigue and weight loss:

Fatigue and weight loss are also related with hyperglycemia. Without insulin like Type 1
Diabetes Mellitus, or Decreased Insulin like Type 2 diabetes, Glucose can not enter in cells
which is the main source of energy for cells, so cells will lake this energy and the patient
will suffer weight loss and fatigue.
Headaches, dizziness, irritability:
Your brain needs a constant supply of energy, if your brain cells don't receive enough
energy, we become tired; most tired people tend to be less tolerant and more irritable!
Dry itchy skin:
Normal skin cells require gamma-linolenic acid (GLA) which our body makes via a
complex metabolic process. In older people and diabetics, this process is impaired and not
enough GLA is produced; this results is chronic, severely dry and itchy skin and condition is
aggravated by soaps, hot baths, detergents, environmental conditions; it is usually worse
during the winter months and most commonly affects legs, feet, and hands but can affect
other areas of the body as well.
Blurred vision Blurred vision:
Diabetes can also affect your eyes as well. Again the cause is High Glucose Levels. High
glucose in blood vessels increases the process of atherosclerosis resulting in a thickening
of blood vessels.Chronically high levels of glucose damage blood vessels in different
organs of the body, usually starting with the retina of the eye and the kidneys and heart;
eventually some blood vessels are lost and remaining ones become leaky which allow
blood and fat to seep out of damaged blood vessels. This makes the retina bleed and swell
which causes blurred vision.
Over a period of years diabetes can also cause new blood vessels to form in the retina of
the eye, as well as damage old vessels. For most people this causes only mild vision

problems. But for others, the effects may be much more serious. In some cases, diabetes
can also lead to total blindness.
Tingling - burning pain in the feet:
Another important symptom of Diabetes. It may sometimes be the very first symptom of
diabetes.Our hands and feet are supplied by Neurons that due to diabetes blood vessels
become thick, similary is the case with neurons, blood supply to these neurons decreases
due to thickening of blood vessels which leads to degeneration of peripheral nerve fibers
(Neurons) throughout the body which commonly leads to a lack of feeling in the feet,
advances up the legs and then the hands and is the most common reason for lower limb
amputations. It can also be very painful. If there is Loss of motor nerve fibers it leads to
muscular weakness.
A loss of sensory nerve fibers leads to loss of feeling and numbness in hands and feet.
Loss of autonomic fibers cause the loss of functions not normally under conscious control
like digestion, heartbeat, blood pressure, and sweating. Neuropathy symptoms tingling,
burning, aching, prickling, sharp jabs of needle like pain can also be caused by nerves
that are damaged or are healing.
Slow healing sores or frequent infections:
Bacteria love high glucose, Diabetes affects your body's ability to heal and fight
infection. Urinary tract infections and vaginal yeast infections can be a particular problem
for women.

PATHOPHYSIOLOGY

Genetic Predisposition (Susceptibility)

Environmental insult
- Viral infection
- Toxic chemical agents

Autoimmunity
-Lymphocyte infiltration
-Insulitis

Immunologic Response
Islet cell antibodies
Cell- mediated immunity

Diagram I

Pathogenesis of Insulin
Dependent DM (Type 1)
cell destruction

Lack of insulin release

Insulin Dependent Diabetes Mellitus (IDDM)

Hereditary Factors

Obesity

Delayed or insufficient insulin

Insulin
secretion
resistance (Receptor defect or other events)

Increased insulin demand

Diagram II
cell exhaustion and dysfunction

Pathogenesis of Non- Insulin Dependent DM (Type 2)

Impaired secretion of insulin

Hyperglycmia

Non- Insulin Dependent DM (NIDDM)

DIAGNOSTIC TEST

DIAGNOSTIC TEST:
Several blood tests are used to measure blood glucose levels, the primary test for
diagnosing diabetes. Additional tests can determine the type of diabetes and its severity.

Random blood glucose test for a random blood glucose test, blood can be
drawn at any time throughout the day, regardless of when the person last ate. A
random blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons
who have symptoms of high blood glucose suggests a diagnosis of diabetes.

Fasting blood glucose test fasting blood glucose testing involves measuring
blood glucose after not eating or drinking for 8 to 12 hours (usually overnight). A
normal fasting blood glucose level is less than 100 mg/dL. A fasting blood
glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done
by taking a small sample of blood from a vein or fingertip.

Hemoglobin A1C test (A1C) The A1C blood test measures the average blood
glucose level during the past two to three months. It is used to monitor blood
glucose control in people with known diabetes, but is not normally used to
diagnose diabetes. Normal values for A1C are 4 to 6 percent .The test is done by
taking a small sample of blood from a vein or fingertip.

Oral glucose tolerance test Oral glucose tolerance testing (OGTT) is the most
sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not
routinely recommended because it is inconvenient compared to a fasting blood
glucose test.

The standard OGTT includes a fasting blood glucose test. The person then drinks a 75
gram liquid glucose solution (which tastes very sweet, and is usually cola or orangeflavored). Two hours later, a second blood glucose level is measured.

TREATMENT

MEDICATIONS:

When diet, exercise and maintaining a healthy weight arent enough, you may need the
help of medication. Medications used to treat diabetes include insulin. Everyone with
type 1 diabetes and some people with type 2 diabetes must take insulin every day to
replace what their pancreas is unable to produce. Unfortunately, insulin cant be taken in
pill form because enzymes in your stomach break it down so that it becomes ineffective.
For that reason, many people inject themselves with insulin using a syringe or an insulin
pen injector,a device that looks like a pen, except the cartridge is filled with insulin.
Others may use an insulin pump, which provides a continuous supply of insulin,
eliminating the need for daily shots.
The most widely used form of insulin is synthetic human insulin, which is chemically
identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic
human insulin isnt perfect. One of its chief failings is that it doesnt mimic the way
natural insulin is secreted. But newer types of insulin, known as insulin analogs, more
closely resemble the way natural insulin acts in your body. Among these are lispro
(Humalog), insulin aspart (NovoLog) and glargine (Lantus).
A number of drug options exist for treating type 2 diabetes, including:

Sulfonylurea drugs- These medications stimulate your pancreas to produce and

release more insulin. For them to be effective, your pancreas must produce some
insulin on its own. Second-generation sulfonylureas such as glipizide (Glucotrol,
Glucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride
(Amaryl) are prescribed most often. The most common side effect of
sulfonylureas is low blood sugar, especially during the first four months of
therapy. Youre at much greater risk of low blood sugar if you have impaired liver

or kidney function.
Meglitinides- These medications, such as repaglinide (Prandin), have effects
similar to sulfonylureas, but youre not as likely to develop low blood sugar.

Meglitinides work quickly, and the results fade rapidly.

Biguanides- Metformin (Glucophage, Glucophage XR) is the only drug in this class
available in the United States. It works by inhibiting the production and release of
glucose from your liver, which means you need less insulin to transport blood sugar into

your cells. One advantage of metformin is that is tends to cause less weight gain than do
other diabetes medications. Possible side effects include a metallic taste in your mouth,
loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea. These
effects usually decrease over time and are less likely to occur if you take the medication
with food. A rare but serious side effect is lactic acidosis, which results when lactic acid
builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness
and drowsiness. Lactic acidosis is especially likely to occur if you mix this medication

with alcohol or have impaired kidney function.

Alpha-glucosidase inhibitors- These drugs block the action of enzymes in your
digestive tract that break down carbohydrates. That means sugar is absorbed into your
bloodstream more slowly, which helps prevent the rapid rise in blood sugar that usually
occurs right after a meal. Drugs in this class include acarbose (Precose) and miglitol
(Glyset). Although safe and effective, alpha-glucosidase inhibitors can cause abdominal
bloating, gas and diarrhea. If taken in high doses, they may also cause reversible liver

damage.
Thiazolidinediones- These drugs make your body tissues more sensitive to insulin and
keep your liver from overproducing glucose. Side effects of thiazolidinediones, such as
rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight
gain and fatigue. A far more serious potential side effect is liver damage. The
thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because
it caused liver failure. If your doctor prescribes these drugs, its important to have your
liver checked every two months during the first year of therapy. Contact your doctor
immediately if you experience any of the signs and symptoms of liver damage, such as
nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your
skin and the whites of your eyes (jaundice).

INSULIN
ADMINISTRATION

BY SYRINGE

Injection techniqueDose preparation

Before each injection, the hands and the injection site should be clean. The top of the
insulin vial should be wiped with 70% isopropyl alcohol. For all insulin preparations,
except rapid- and short-acting insulin and insulin glargine, the vial or pen should be

gently rolled in the palms of the hands (not shaken) to resuspend the insulin. An amount
of air equal to the dose of insulin required should first be drawn up and injected into the
vial to avoid creating a vacuum. For a mixed dose, putting sufficient air into both bottles
before drawing up the dose is important. When mixing rapid- or short-acting insulin with
intermediate- or long-acting insulin, the clear rapid- or short-acting insulin should be
drawn into the syringe first.
After the insulin is drawn into the syringe, the fluid should be inspected for air bubbles.
One or two quick flicks of the forefinger against the upright syringe should allow the
bubbles to escape. Air bubbles themselves are not dangerous but can cause the injected
dose to be decreased.
Injection procedures
Injections are made into the subcutaneous tissue. Most individuals are able to lightly
grasp a fold of skin and inject at a 90 angle. Thin individuals or children can use short
needles or may need to pinch the skin and inject at a 45 angle to avoid intramuscular
injection, especially in the thigh area. Routine aspiration (drawing back on the injected
syringe to check for blood) is not necessary. Particularly with the use of insulin pens, the
needle should be embedded within the skin for 5 s after complete depression of the
plunger to ensure complete delivery of the insulin dose.
Patients should be aware that air bubbles in an insulin pen can reduce the rate of insulin
flow from the pen; underdelivery of insulin can occur when air bubbles are present, even
if the needle remains under the skin for as long as 10 s after depressing the plunger. Air
can enter the insulin pen reservoir during either manufacture or filling if the needle is left
on the pen between injections. To prevent this potential problem, avoid leaving a needle
on a pen between injections and prime the needle with 2 units of insulin before injection.
If an injection seems especially painful or if blood or clear fluid
is seen after withdrawing the needle, the patient should apply pressure for 58 s without
rubbing. Blood glucose monitoring should be done more frequently on a day when this
occurs. If the patient suspects that a significant portion of the insulin dose was not

administered, blood glucose should be checked within a few hours of the injection. If
bruising, soreness, welts, redness, or pain occur at the injection site, the patients injection
technique should be reviewed by a physician or diabetes educator. Painful injections may
be minimized by the following:
1. Injecting insulin at room temperature.
2. Making sure no air bubbles remain in the syringe before injection.
3. Waiting until topical alcohol (if used) has evaporated completely before injection.
4. Keeping muscles in the injection area relaxed, not tense, when injecting.
5. Penetrating the skin quickly.
6. Not changing direction of the needle during insertion or withdrawal.
7. Not reusing needles.
Some individuals may benefit from the use of prefilled syringes (e.g., the visually
impaired, those dependent on others for drawing their insulin, or those traveling or eating
in restaurants). Prefilled syringes are stable for up to 30 days when kept in a refrigerator. If
possible, the syringes should be stored in a vertical position, with the needle pointing
upward, so that suspended insulin particles do not clog the needle. The predrawn syringe
should be rolled between the hands before administration. A quantity of syringes may be
premixed and stored. The effect of premixing of insulins on glycemic control should be
assessed by a physician, based on blood glucose results obtained by the patient. When
premixing is required, consistency of technique and careful blood glucose monitoring are
especially important.

INJECTION TECHNIQUE

Injection site
Insulin may be injected into the subcutaneous tissue of the upper arm and the anterior and
lateral aspects of the thigh, buttocks, and abdomen (with the exception of a circle with a

2-inch radius around the navel). Intramuscular injection is not recommended for routine
injections. Rotation of the injection site is important to prevent lipohypertrophy or
lipoatrophy. Rotating within one area is recommended (e.g., rotating injections
systematically within the abdomen) rather than rotating to a different area with each
injection. This practice may decrease variability in absorption from day to day. Site
selection should take into consideration the variable absorption between sites. The
abdomen has the fastest rate of absorption, followed by the arms, thighs, and buttocks.
Exercise increases the rate of absorption from injection sites, probably by increasing
blood flow to the skin and perhaps also by local actions. Areas of lipohypertrophy usually
show slower absorption. The rate of absorption also differs between subcutaneous and
intramuscular sites. The latter is faster and, although not recommended for routine use,
can be given under other circumstances (e.g., diabetic ketoacidosis or dehydration).

NURSING
MANAGEMENT

NURSING MANAGEMENT
Nursing Diagnosis for Diabetes Mellitus

Nursing diagnoses in patients with diabetes mellitus are:

1. Fluid Volume Deficit related to osmotic dieresis.
2. Imbalanced Nutrition less than body requirements related to insulin insufficiency,
decreased oral input.
3. Risk for Infection related to inadequate peripheral defense, changes in circulation,
high blood sugar levels, invasive procedures and skin damage.
4. Fatigue related to decreased metabolic energy production, changes in blood
chemistry, insulin insufficiency and increased energy demand.
5. Knowledge Deficit related to condition, prognosis and treatment needs.

Nursing Intervention and Implementation for Diabetes Mellitus

1). Fluid Volume Deficit

Expected outcomes:
Patients showed an improvement in fluid balance; spending adequate urine (normal
range), vital signs stable, clear peripheral pulse pressure, good skin turgor,.
Intervention / Implementation:
1. Monitor vital signs, note the presence of orthostatic blood pressure.
R: Hypovolemia can be manifested by hypotension and tachycardia.
2. Assess breathing and breath patterns.
R: The lungs secrete carbonic acid is produced through respiration compensated
respiratory alkalosis, the state of ketoacidosis.
3. Assess temperature, color and moisture.
R: Fever, chills, and diaphoresis is common in the infection process. Fever with skin
redness, dry, maybe a picture of dehydration.
4. Assess peripheral pulses, capillary refill, skin turgor and mucous membranes.
R: Is an indicator of the level of dehydration or adequate circulating volume.
5. Monitor intake and output. Record the urine specific gravity.
R: Provide the estimated need for fluid replacement, renal function and the effectiveness
of a given therapy.
6. Measure body weight every day.
R: Provide the best results of the assessment of the status of ongoing fluid and further in
giving replacement fluids.

2). Imbalanced Nutrition, Less Than Body Requirements

Expected outcomes:
Patients are able to express an understanding of substance abuse, decrease the amount of

intake (diet on nutritional status).

Demonstrate behaviors, lifestyle changes to improve and maintain a proper weight.

Intervention / Implementation:
1. Measure body weight per day as indicated.
R: Knowing eating adequate income.
2. Determine the diet program and diet of patients compared with food that can be spent
on the patient.
R: Identify deviations from the requirements.
3. Auscultation of bowel sounds, record the presence of abdominal pain / abdominal
bloating, nausea, vomiting, keep fasting as indicated.
R: Influence of intervention options.
4. Observation of the signs of hypoglycemia, such as changes in level of consciousness,
cold / humid, rapid pulse, hunger and dizziness.
R: Potentially life-threatening, which must be multiplied and handled appropriately.
5. Collaboration in the delivery of insulin, blood sugar tests and diet.
R: It is useful to control blood sugar levels.

3). Risk for Infection

Expected outcomes:
Identify individual risk factors and potential interventions to reduce infection.
Maintain a safe aseptic environment.

Intervention / Implementation
1. Observation for signs of infection and inflammation such as fever, redness, pus in the
wound, purulent sputum, urine color cloudy and foggy.
R: incoming patients with infections that normally might have been able to trigger a state
ketosidosis or nosocomial infections.
2. Increase prevention efforts by performing good hand washing, each contact on all
items related to the patient, including his or her own patients.
R: prevention of nosocomial infections.
3. Maintain aseptic technique in invasive procedures (such as infusion, catheter folley,
etc.).
R: Glucose levels in the blood will be the best medium for the growth of germs.
4. Attach catheter / perineal care do well.
R: Reduce the risk of urinary tract infection.
5. Give skin care with regular and earnest. Massage depressed bone area, keep skin dry,
dry linen and tight (not wrinkled).
R: peripheral circulation can be impaired which puts patients at increased risk of damage
to the skin / eye irritation and infection.
6. Position the patient in semi-Fowler position.
R: Makes it easy for the lung to expand, lowering the risk of hypoventilation.

4 . Knowledge Deficit
Expected outcomes:
Perform the necessary procedures and explain the rationale of an action.
Initiate the necessary lifestyle changes and participate in treatment regimen.

Intervention / Implementation:
1. Assess the level of knowledge of the client and family about the disease.
R: Find out how much experience and knowledge of the client and family about the
disease.
2. Give an explanation to the client about diseases and conditions now.
R: By knowing the diseases and conditions now, clients and their families will feel calm
and reduce anxiety.
3. Encourage clients and families to pay attention to her diet.
R: Diet and proper diet helps the healing process.
4. Ask the client and reiterated family of materials that have been given.
R: Knowing how much understanding of clients and their families and assess the success
of the action taken.

SELF CARE ACTIVITIES

&

EDUCATION OF
DIABETIC PATIENT

SELF-MONITORING OF BLOOD GLUCOSE

The impact of glycemic control on diabetes complications have included SMBG as part of
multifactorial interventions, suggesting that SMBG is a component of effective therapy.
SMBG allows patients to evaluate their individual response to therapy and assess whether

glycemic targets are being achieved. Results of SMBG can be useful in preventing
hypoglycemia and adjusting medications, MNT, and physical activity.
The frequency and timing of SMBG should be dictated by the particular needs and goals of
the patients. Daily SMBG is especially important for patients treated with insulin to monitor
for and prevent asymptomatic hypoglycemia. For most patients with type 1 diabetes and
pregnant women taking insulin, SMBG is recommended three or more times daily. The
optimal frequency and timing of SMBG for patients with type 2 diabetes is not known, but
should be sufficient to facilitate reaching glucose goals. When adding to or modifying
therapy, type 1 and type 2 diabetic patients should test more often than usual. The role of
SMBG in stable diet-treated patients with type 2 diabetes is not known.
Because the accuracy of SMBG is instrument- and user-dependent , it is important
for health care providers to evaluate each patients monitoring technique, both initially and at
regular intervals thereafter. In addition, optimal use of SMBG requires proper interpretation
of the data. Patients should be taught how to use the data to adjust food intake, exercise, or
pharmacological therapy to achieve specific glycemic goals. Health professionals should
evaluate at regular intervals the patients ability to use SMBG data to guide treatment.

Recommendations

SMBG is an integral component of diabetes therapy.

Include SMBG in the management plan.

Instruct the patient in SMBG and routinely evaluate the patients technique and
ability to use data to adjust therapy.

PHYSICAL ACTIVITY

Regular exercise has been shown to improve blood glucose control, reduce cardiovascular
risk factors, contribute to weight loss, and improve well-being. Furthermore, regular exercise
may prevent type 2 diabetes in high-risk individuals.
Before beginning a physical activity program, the patient with diabetes should have a
detailed medical evaluation with appropriate diagnostic studies. This examination should
screen for the presence of macro- and micro vascular complications that may be worsened by
the physical activity program (see next section regarding coronary heart disease [CHD]
screening). Identification of areas of concern will allow the design of an individualized
physical activity plan that can minimize risk to the patient.
All levels of physical activity, including leisure activities, recreational sports, and
competitive professional performance, can be performed by people with diabetes who do not
have complications and have good glycemic control. The ability to adjust the therapeutic
regimen (insulin therapy and MNT) to allow safe participation is an important management
strategy.
Recommendations

A regular physical activity program, adapted to the presence of complications, is

recommended for all patients with diabetes who are capable of participating.

DIABETIC RETINOPATHY SCREENING AND TREATMENT

Diabetic retinopathy is a highly specific vascular complication of both type 1 and

type 2 diabetes. The prevalence of retinopathy is strongly related to the duration of
diabetes. Diabetic retinopathy is estimated to be the most frequent cause of new cases
of blindness among adults aged 2074 years.
Intensive diabetes management with the goal of achieving near normoglycemia has
been shown in large prospective randomized studies to prevent and/or delay the onset
of diabetic retinopathy .In addition to glycemic control, several other factors seem to
increase the risk of retinopathy. The presence of nephropathy is associated with
retinopathy. High blood pressure is an established risk factor for the development of
macular edema and is associated with the presence of proliferative diabetic
retinopathy (PDR). Lowering blood pressure, has been shown to decrease the
progression of retinopathy.
Recommendations
General recommendations

Optimal glycemic control can substantially reduce the risk and progression of
diabetic retinopathy.

Optimal blood pressure control can reduce the risk and progression of diabetic
retinopathy.

Aspirin therapy does not prevent retinopathy or increase the risks of hemorrhage.
Treatment

Laser therapy can reduce the risk of vision loss in patients with HRCs.

Promptly refer patients with any level of macular edema, severe NPDR, or any
PDR to an ophthalmologist who is knowledgeable and experienced in the
management and treatment of diabetic retinopathy.

DIABETIC RETINOPATHY

FOOT CARE
Amputation and foot ulceration are one of the most common consequences of diabetic
neuropathy and a major cause of morbidity and disability in people with diabetes. Early
recognition and management of independent risk factors can prevent or delay adverse
outcomes.

The risk of ulcers or amputations is increased in people who have had diabetes >10 years,
are male, have poor glucose control, or have cardiovascular, retinal, or renal
complications. The following foot-related risk conditions are associated with an increased
risk of amputation:

Peripheral neuropathy with loss of protective sensation.

Altered biomechanics (in the presence of neuropathy).

Evidence of increased pressure (erythema, hemorrhage under a callus).

Bony deformity.

Peripheral vascular disease (decreased or absent pedal pulses).

A history of ulcers or amputation.

Severe nail pathology.

Recommendations

A multidisplinary approach is recommended for persons with foot ulcers and highrisk feet, especially those with a history of prior ulcer or amputation.

The foot examination can be accomplished in a primary care setting and should
include the use of a tuning fork, palpation, and a visual examination.

Educate all patients, especially those with risk factors or prior lower-extremity
complications, about the risk and prevention of foot problems and reinforce self-care
behavior.

Refer high-risk patients to foot care specialists for ongoing preventive care
and life-long surveillance.

Refer patients with significant claudication for further vascular assessment

and consider exercise and surgical options.

Perform a comprehensive foot examination annually on patients with

diabetes to identify risk factors predictive of ulcers and amputations. Perform
a visual inspection of patients feet at each routine visit.

TREATMENT:The treatment of foot problems depends upon the presence and severity of foot
ulcers.Treatment of superficial ulcers (involving only the top layers of skin) usually
includes cleaning the ulcer and removing dead skin and tissue (debridement) by a
healthcare provider. There are a number of debridement techniques available.If the foot is
infected, antibiotics are generally prescribed. The patient (or someone in his or her
household) should clean the ulcer and apply a clean dressing twice daily. The patient
should keep weight off the foot ulcer as much as possible, meaning that they should not
walk with the affected foot. The foot should be elevated when sitting or lying down. The
ulcer should be checked by a healthcare provider at least once per week to make sure that
the ulcer is improving.
Ulcers that extend into the deeper layers of the foot, involving muscle and bone, usually
require hospitalization. More extensive laboratory testing and x-rays may be done, and
intravenous antibiotics are often necessary. Surgery may be necessary to remove infected
bone or to place a cast on the foot to take pressure off the ulcer.If part of the toes or foot
become severely damaged, causing areas of dead tissue (gangrene), partial or complete
amputation may be required.

DIABETIC FOOT

DIETARY ADVICE

Eat three meals a day. Avoid skipping meals and space breakfast, lunch and evening meal
out over the day.

At each meal include starchy carbohydrate foods, eg bread, pasta, chapatis, potatoes,
yam, noodles, rice and cereals. Eat more slowly absorbed (low glycaemic index) foods, eg
pasta, basmati or easy cook rice, grainy breads such as granary, pumpernickel and rye, new
potatoes, sweet potato and yam, porridge oats, All-Bran and natural muesli.

Reduce the fat in the diet, especially saturated fats. Use unsaturated fats or oils, especially
monounsaturated fats, eg olive oil and rapeseed oil.

Eat more fruit and vegetables. Aim for at least five portions a day.

Eat more beans and lentils, eg kidney beans, butter beans, chickpeas or red and green
lentils.

Eat at least two portions of oily fish a week, eg mackerel, sardines, salmon and pilchards.
Limit sugar and sugary foods.

Reduce salt in the diet to 6 g or less per day.

Drink alcohol only in moderation.

Don't use diabetic foods or drinks (they are expensive and of no benefit).

Diabetes is a condition in which the amount of glucose (sugar) in the blood is too high
due to a lack of insulin. Eating the right food at regular intervals during the day helps to
keep blood glucose at satisfactory levels.

It is important to AVOID HIGH SUGAR FOODS. The majority of high sugar foods have
suitable replacements for diabetics, some of which are included in the table below.

A starchy food MUST be included at every meal and preferably in similar amounts each
day. If possible choose starches that are high in fibre.

It is important to limit the amount of fat in your diet, as too much fat can cause weight
gain, increase blood fat levels and affect blood sugar control.

FOOD PYRAMID IN DIABETES

DIET PLAN
Items
Carbohydrate

Dont Eat
Maida , Sujee, Noodles, White

Healthy Eat
Atta, Whole Wheat , Brown Bread,

Vegetable

Rice, Butter & Cream Biscuits

Potato, Arbi, Shakerkund,

Maize, Bajra, Wheat Biscuits

Green Vegetables, Spaneesh,
Coriander, Pudina, Beans,
Gawarfali, Cabbage, Brinjal, Karela,

Fruits

Protein

Avoid Fruits Juice Like- Banana,

Tomato, Shimla Mirch, Radish

Apple , Orange, Jamun, Guavava,

Grapes, Cheku, Leechi,

Papaya, Naspati, Amala, Carrot,

Seetaphal
Meat- Red Meat, Yellow Egg

Pomograine
Whole Dal, Black Channa, White

Part, Butter, Malai, Cheese

Channa, Rajma, Soyabean, Meat

White, Chicken, Fish, Egg White

Drinks

Cold Drinks, Sugar Mixed

Part, Paneer, Skimmed Milk

Vegetable Soup, Tomato Soup,

Others

Drinks
Fast Food, Pizza, Burger, Chips,

Carrot Juice, Lemon Water, Jaljeera

Veg Dossa, Uttpam, Cheela, Simple

Puri, Snacks, Namkeen, Samosa,

Soup, Lemon Water, Chach, Termini

Pratha, Kachori, Pakodi

Water, Fat Free Milk

DIET CHART
TIME
Morning- 7 A.M.
Breakfast

FOOD STATUS
Tea/ Milk ( without sugar)
1. Milk chach
2. Daliya
3. Poha ( namkeen)

QUANTITY
1 Cup
1 Cup
1 katori

4.
5.
6.
7.

Daliya Rabdi
Sparouts
Idli / Simple Dosa
Rote / Bread + fruits

1 katori
1 katori
1 katori
1 katori

Lunch

Evening Tea

Dal

1 katori
1 katori

Rice

1 katori

Chapatti ( without ghee)

1 chapati

Vegetables

1 katori

Curd / Rayta / Kadi

1 katori

Salad
Tea / Milk / Chach (without sugar)

1 katori
1 Cup/ 1 glass

Steamed channa / Poha

Permal chiwds + Fruits
Dinner

Dal + Rice + Chapati ( Missi roti) +

1 katori

Curd/ Rayta / Kadi + Fruits

1 katori

EXERCISE
Regular physical activity improves insulin resistance and lipid profile (reduction in
triglyceride and increase in high-density lipoprotein (HDL)) and lowers blood pressure
(although blood pressure will rise during exercise).
The metabolic benefits in type 2 diabetes are lost within 3-10 days of stopping regular
exercise.
Physical activity also protects against the development of type 2 diabetes.

Diabetes recommendations
The recommended minimum amount of activity for:

Adults - 30 minutes on at least five days of each week.

Children - one hour each day.

It is essential to find activities that are enjoyable, achievable and sustainable, eg walks,
dancing, swimming, bowling, cycling, golf, playing with the children, DIY.

Exercise and type 2 Diabetes

The possible benefits of exercise for the patient with type 2 diabetes are substantial, and
recent studies strengthen the importance of long-term exercise programs for the treatment
and prevention of this common metabolic abnormality and its complications. Specific
metabolic effects can be highlighted as follows.

Glycemic control
Several long-term studies have demonstrated a consistent beneficial effect of regular
exercise training on carbohydrate metabolism and insulin sensitivity, which can be
maintained for at least 5 years. These studies used exercise regimens at an intensity of 50
80% Vo2max three to four times a week for 3060 min a session. Improvements in
HbA1c were generally 1020% of baseline and were most marked in patients with mild
type 2 diabetes and in those who are likely to be the most insulin resistant. It remains true,
unfortunately, that most of these studies suffer from inadequate randomization and
controls, and are confounded by associated lifestyle changes. Data on the effects of
resistance exercise are not available for type 2 diabetes although early results in normal
individuals and patients with type 1 disease suggest a beneficial effect.
It now appears that long-term programs of regular exercise are indeed feasible for patients
with impaired glucose tolerance or uncomplicated type 2 diabetes with acceptable
adherence rates. Those studies with the best adherence have used an initial period of
supervision, followed by relatively informal home exercise programs with regular,
frequent follow-up assessments. A number of such programs have demonstrated sustained

relative improvements in Vo2maxover many years with little in the way of significant
complications.

Prevention of cardiovascular disease

In patients with type 2 diabetes, the insulin resistance syndrome continues to gain support
as an important risk factor for premature coronary disease, particularly with concomitant
hypertension, hyperinsulinemia, central obesity, and the overlap of metabolic
abnormalities of hypertriglyceridemia, low HDL, altered LDL, and elevated FFA. Most
studies show that these patients have a low level of fitness compared with control patients,
even when matched for levels of ambient activity, and that poor aerobic fitness is
associated with many of the cardiovascular risk factors. Improvement in many of these
risk factors has been linked to a decrease in plasma insulin levels, and it is likely that
many of the beneficial effects of exercise on cardiovascular risk are related to
improvements in insulin sensitivity.

Hyperlipidemia
Regular exercise has consistently been shown to be effective in reducing levels of
triglyceride-rich VLDL. However, effects of regular exercise on levels of LDL cholesterol
have not been consistently documented. With one major exception, most studies have
failed to demonstrate a significant improvement in levels of HDL in patients with type 2
diabetes, perhaps because of the relatively modest exercise intensities used.

EXERCISES

Fibrinolysis
Many patients with type 2 diabetes have impaired fibrinolytic activity associated with
elevated levels of plasminogen activator inhibitor-1 (PAI-1), the major naturally
occurring inhibitor of tissue plasminogen activator (TPA). Studies have demonstrated an

association of aerobic fitness and fibrinolysis. There is still no clear consensus on

whether physical training results in improved fibrinolytic activity in these patients.

Obesity
Data have accumulated suggesting that exercise may enhance weight loss and, in
particular, weight maintenance when used along with an appropriate calorie-controlled
meal plan. There are few studies specifically dealing with this issue in type 2 diabetes,
and much of the available data is complicated by the simultaneous use of unusual diets
and other behavioral interventions. Of particular interest are studies suggesting a
disproportionate effect of exercise on loss of intra-abdominal fat, the presence of which
has been associated most closely with metabolic abnormalities.

Exercise and type 1 Diabetes

All levels of exercise, including leisure activities, recreational sports, and competitive
professional performance, can be performed by people with type 1 diabetes who do not
have complications and are in good blood glucose control (note previous section). The
ability to adjust the therapeutic regimen (insulin and medical nutrition therapy) to allow
safe participation and high performance has recently been recognized as an important
management strategy in these individuals. In particular, the important role played by the
patient in collecting self-monitored blood glucose data of the response to exercise and
then using these data to improve performance and enhance safety is now fully accepted.
Hypoglycemia, which can occur during, immediately after, or many hours after exercise, can
be avoided. This requires that the patient have both an adequate knowledge of the metabolic
and hormonal responses to exercise and well-tuned self-management skills. The increasing
use of intensive insulin therapy has provided patients with the flexibility to make appropriate
insulin dose adjustments for various activities.

BIBLIOGRAPHY: Text books

1. Brunner and Siddharth, (2004) Text book of medical surgical-surgical nursing

Philadelphia : Lippincott Williams and Wilkins.
2. Lewis and Coller,(2003) Medical Surgical nursing. New York (USA) Mosby
Publication.
3. Neders, Nadagh P,(2003). Individualized education can improve foot care for
patients with diabetes. Home health care nurse.
4. Usha Ravindran Nair (2009), Text book of medical surgical-surgical nursing,
Cochin (India), JAYPEE Publication.
5. Sandra M. Nettina, Lippincott manual of nursing practice, Baltimore,
Maryland: Lippincott Williams and Wilkins.
6. S.N. Chugh (2013), Text Book of Medical Surgical Nursing, AVICHAL
Publishing Company.
7. T. K. Indrani , (2008) Nursing Manual of Nutrition and Therapeutic diet JAPYEE
Publication.
8. VIJAYA D. Joshi (2010),Hand Book of Nutrition & Dietetics Vora medical
Publications.
9. Dr. Shrinandan Bansal, (2010) food and nutrition AITBS PULICATION, INDIA
10. Harbans Lal, (2010), food & nutrition CBS Publication.
11. Dr. M. Swaminathan, (2010), Handbook of Food and Nutrition, Bangalore:
BAPPPCO Publications
12. Black J.M., Hawks (2009), Medical Surgical Nursing, New Delhi, Saunders
Publications.
13. Luckman, (2001), Medical Surgical Nursing, Philadelphia : W.B. Saunders
Publications.

Research study and Articles

1. Miss Anitha .S(2004), A study to assess the knowledge and attitude of self care
activities among patients with diabetes mellitus, Chennai.

2. Walking K. A, (2000) Study on effect at a adult self regulation of Diabetes on

quality of life outcomes, Columbia.

Internet
1.
2.
3.
4.
5.

http://library.med.utah.edu/WebPath/Tutorial/Diabetes/Diabetes.html
http://www.nlm.nih.gov/medlineplus/diabetes.html
wikipedia.org/wiki/Honeymoon period_(diabetes)
http://www.disabled-world.com/artman/publish/diabetesmellitus.shtml
http://rnspeak.com/pathophysiology/diabetes-pathophysiology-diseases-processdiagram.