DIABETES MELLITUS

Nelia S. Bañaga – Perez RN, MSN, MAEd

Northeastern College
Nursing Department
Santiago City, Philippines
 DIABETES MELLITUS
• An endocrine disorder in which there is
insufficient amount or lack of insulin secretion
to metabolize carbohydrates.

• It is characterized by hyperglycemia, glycosuria

and ketonuria.
 Diabetes Mellitus
Pathophysiology
• The beta cells of the Islets of Langerhan of the
Pancreas gland are responsible for secreting
the hormone insulin for the carbohydrate
metabolism.

• Remember the concept - sugar into the cells.

 Diabetes Mellitus
Types
• Type 1 - IDDM • Type 2 - NIDDM
– little to no insulin – some insulin produced
produced – 90% hereditary
– 20-30% hereditary
• Other types include Secondary Diabetes :
– Ketoacidosis – Genetic defect beta cell or
insulin
– Disease of exocrine pancreas
– Drug or chemical induced
• Gestational – Infections-pancreatitits
– Others-steroids,
– overweight; risk for Type
2
 INSULIN
• Insulin is a protein made of 2 chains- alpha and beta
• Preproinsulin is produced initially
– Precursor molecule that is inactive
– Must be made smaller before becoming active
• Proinsulin
– Precursor that includes alpha and beta chains
– Also has a C-peptide chain
– C-peptide levels are used to measure rate that beta cells
secrete insulin
 INSULIN
• Insulin allows glucose to move into cells to make energy
• Liver is first major organ to be reached
– Promotes production and storage of glycogen (glycogenisis)
– Inhibits glycogen breakdown into glucose (glycogenolysis)
– Increases protein and lipid synthesis
– Inhibits tissue breakdown by inhibiting liver glycogenolysis
(ketogenesis- converts fats to acids) & gluconeogenisis
(conversion of proteins to glucose)
– In muscle, promotes protein and glycogen synthesis
– In fat cells, promotes triglyceride storage
 INSULIN
• Pancreas secretes 40-50 units of insulin daily in
two steps:
– Secreted at low levels during fasting ( basal insulin
secretion
– Increased levels after eating (prandial)
– An early burst of insulin occurs within 10 minutes
of eating
– Then proceeds with increasing release as long as
hyperglycemia is present
 GLUCOSE HOMEOSTASIS
• Glucose is main fuel for CNS
• Brain cannot make or store, therefore needs
continuous supply
• Fatty acids can be used when glucose is not
available ( triglycerides)
• Need 68-105 mg/dL to support brain
• Decreased levels of glucose, insulin release is
stopped with glucagon released
 GLUCOSE
• Glucagon causes release of glucose from liver
– Liver glucose is made thru glycogenolysis (glucogen to
glucose) &
– Gluconeogenesis
• When liver glucose is not available, lypolysis
occures ( breakdown of fat) OR
• Proteinlysis (breakdown of amino acids)
 ABSENCE OF INSULIN
• Insulin needed to move glucose into cells
• Without insulin, body enters a state of
breaking down fats and proteins
• Glucose levels increase (hyperglycemia)
 Absence of Insulin
• Hyperglycemia
• Polyuria
• Polydipsia
• Polyphagia
• Hemoconcentration, hypervolemia,
hyperviscosity, hypoperfusion, and hypoxia
• Acidosis, Kussmaul respiration
• Hypokalemia, hyperkalemia, or normal
serum potassium levels
 Assessment
• History
• Blood tests
– Fasting blood glucose test: two tests > 126 mg/dL
– Oral glucose tolerance test: blood glucose > 200 mg/dL
at 120 minutes
– Glycosylated hemoglobin (Glycohemoglobin test) assays
– Glucosylated serum proteins and albumin
• FSBS – (finger stick) monitoring blood sugar
 Urine Tests
• Urine testing for ketones
• Urine testing for renal function
• Urine testing for glucose
 Diabetes Mellitus
Clinical Manifestation
• Hyperglycemia • Hypoglycemia
– Weak, diaphoretic, sweat,
– Three P’s - pallor, tremors, nervous,
• Polyuria hungry, diplopia, confusion,
aphasia, vertigo, convulsions
• Polyphagia – Treatment - OJ with sugar, or
IV glucose
• Polydispsia

• Sudden onset
• Gradual Onset
 Hyperglycemia - Clinical
Manifestations
• Three P’s – polyuria, • Fever
polydypsia, • Hypokalemia
polyphagia • Hyponatremia
• Glycosuria • Seizure
• Dehydration • Coma
• Hypotension
• Mental Changes Life Threatening!!!
 Risk for Injury Related to
Hyperglycemia
• Interventions include:
– Dietary interventions, blood glucose
monitoring, medications
– Oral Drugs Therapy
(Continued)
 Risk for Injury Related to
Hyperglycemia (Continued)
– Oral therapy
• Sulfonylurea agents
• Meglitinide analogues
• Biguanides
• Alpha-glucosidase inhibitors
• Thiazolinedione antidiabetic agents
 Oral Hypoglcemias
Key Points
• Monitor serum glucose levels
• Teach patient signs and symptoms of
hyper/hypoglycemia
• Altered liver, renal function will affect medication
action
• Avoid OTC meds without MD approval
• Assess for GI distress and sensitivity
• Know appropriate time to administer med
 Diet Therapy
• Goals of diet therapy
• Principles of nutrition in diabetes
– Protein, fats and carbohydrates, fiber,
sweeteners, fat replacers
– Alcohol
– Food labeling
– Exchange system, carbohydrate counting
– Special considerations for type 1 and type 2
diabetes
 Diabetes Mellitus
Diet
• American Diabetic
Association
• Food groups/ exchanges
• Carbohydrates - 60%
• Fats - 30%
• Protein - 12-20%
 Diabetes - Monitoring Glucose
Levels
• Urine - Ketones

• FSBS

• Wear ID Bracelet
Diabetes - Treatment
Exercise
• Purpose - controls blood
glucose and lowers
blood glucose

• Purpose - reduce the

amount of insulin
needed
 Exercise Therapy
• Benefits of exercise
• Risks related to exercise
• Screening before starting exercise program
• Guidelines for exercise
• Exercise promotion
 Drug Therapy
• Drug administration
• Drug selection
• Insulin therapy:
– Insulin analogue
– Short-acting insulin
– Concentrated insulin
– Intermediate
(Continued)
 Drug Therapy (Continued)
– Fixed-combination
– Long-acting
– Buffered insulins
 Insulin Regimens
• Single daily injection protocol
• Two-dose protocol
• Three-dose protocol
• Four-dose protocol
• Combination therapy
• Intensified therapy regimens
 Pharmacokinetics of Insulin
• Injection site
• Absorption rate
• Injection depth
• Time of injection
• Mixing insulins
 Complications of Insulin Therapy
• Hypoglycemia
• Lipoatrophy
• Dawn phenomenon
• Somagyi's phenomenon
 Alternative Methods of Insulin
Administration
• Continuous subcutaneous infusion of insulin
• Implanted insulin pumps
• Injection devices
• New technology includes:
– Inhaled insulin
– Transdermal patch (being tested)
 Client Education
• Storage and dose preparation
• Syringes
• Blood glucose monitoring
• Interpretation of results
• Frequency of testing
• Blood glucose therapy goals
 Diabetic Education -
Preventive Medicine
• Proper skin and foot • Diabetic Neuropathy
care
• Proper Eye Exam • Diabetic Retinopathy

• Proper diet and fluids • Diabetic Nephropathy

• Diabetic gastroparesis
 Diabetes Mellitus
Complications
• Hyperglycemia

• Hypoglycemia

• Diabetic Ketoacidosis

• Hyperosmolar Hyperglycemic Nonketotic

Syndrome
 Acute Complications of Diabetes
• Diabetic ketoacidosis
• Hyperglycemic-hyperosmolar-nonketotic
syndrome
• Hypoglycemia from too much insulin or too
little glucose
Diabetic Ketoacidosis
Potential for Diabetic Ketoacidosis
• Interventions include:
– Monitoring for manifestations
– Assessment of airway, level of consciousness,
hydration status, blood glucose level
– Management of fluid and electrolytes
(Continued)
Potential for Diabetic Ketoacidosis
(Continued)
– Drug therapy goal: to lower serum glucose by 75
to 150 mg/dL/hr
– Management of acidosis
– Client education and prevention
 Complication – Ketoacidosis
Treatment
• Patent airway • Administration of Na
• Suctioning Bicarb
• Cardiac monitoring • Foley – monitor urinary
Vital Signs output
•
• Central venous pressure • I&O
Blood work – ABG, BS, • Frequent Repositioning
•
chemistry panel
 Complication – HHNC
Hyperosmolar Hyperglycemic
Non-Ketotic Coma
• Signs and Symptoms
• Fluid moves from inside to
– Hypotension
outside cell vausing diuresis
– Mental changes
and loss of Na+ and K+
– Dehydration
– Hypokalemia
• Treatment - Give insulin and – Hyponatremia
correct fluid and
electrolytes imbalance

– Life Threatening!!!
Chronic Complications of Diabetes
• Cardiovascular disease
• Cerebrovascular disease
• Retinopathy (vision) problems
• Diabetic neuropathy
• Diabetic nephropathy
• Male erectile dysfunction
 Diabetes Mellitus
Nursing Process
• Assessment – Medicines, Allergies, Symptoms, Family Hx
• Nursing Diagnosis- Anxiety and Fear, Altered Nutrition, Pain,
Fluid Volume Deficit
• Planning – Address the nursing diagnosis
• Implementation – Prevent complications, monitor blood
sugars, administer meds and diet, teach diet and meds, Asess
, Assess, Assess
• Evaluation- Goals, EOC’s
Whole-Pancreas Transplantation
• Operative procedure
• Rejection management
• Long-term effects
• Complications
• Islet cell transplantation hindered by limited
supply of beta cells and problems caused by
antirejection drugs
Risk for Delayed Surgical Recovery
• Interventions include:
– Preoperative care
– Intraoperative care
– Postoperative care and monitoring includes care
of:
• Cardiovascular
• Renal
• Nutritional
Risk for Injury Related to Sensory
Alterations
• Interventions and foot care practices:
– Cleanse and inspect the feet daily.
– Wear properly fitting shoes.
– Avoid walking barefoot.
– Trim toenails properly.
– Report nonhealing breaks in the skin.
 Wound Care
• Wound environment
• Debridement
• Elimination of pressure on infected area
• Growth factors applied to wounds
 Chronic Pain
• Interventions include:
– Maintenance of normal blood glucose levels
– Anticonvulsants
– Antidepressants
– Capsaicin cream
 Risk for Injury Related to Disturbed Sensory
Perception: Visual
• Interventions include:
– Blood glucose control
– Environmental management
• Incandescent lamp
• Coding objects
• Syringes with magnifiers
• Use of adaptive devices
Ineffective Tissue Perfusion: Renal
• Interventions include:
– Control of blood glucose levels
– Yearly evaluation of kidney function
– Control of blood pressure levels
– Prompt treatment of UTIs
– Avoidance of nephrotoxic drugs
– Diet therapy
– Fluid and electrolyte management
 Potential for Hypoglycemia
• Blood glucose level < 70 mg/dL
• Diet therapy: carbohydrate replacement
• Drug therapy: glucagon, 50% dextrose,
diazoxide, octreotide
• Prevention strategies for:
– Insulin excess
– Deficient food intake
– Exercise
– Alcohol
 Potential for Hyperglycemic-Hyperosmolar
Nonketotic Syndrome and Coma

Interventions include:
Monitoring
Fluid therapy: to rehydrate the client
and restore normal blood glucose
levels within 36 to 72 hr
Continuing therapy with IV regular
insulin at 10 units/hr often needed to
reduce blood glucose levels
 Health Teaching
• Assessing learning needs
• Assessing physical, cognitive, and emotional
limitations
• Explaining survival skills
• Counseling
• Psychosocial preparation
• Home care management
• Health care resources
 Diabetes Mellitus
Summary
• Treatable, but not curable.
• Preventable in obesity, adult client.
• Diagnostic Tests
• Signs and symptoms of hypoglycemia and
hyperglycemia.
• Treatment of hypoglycemia and hyperglycemia – diet
and oral hypoglycemics.
• Nursing implications – monitoring, teaching and
assessing for complications.
 DIABETES SELF CARE STAR
• MEALS

MONITORING MEDICATIONS
* PLASMA *INSULIN
*FEET *ORAL
AGENTS

MANAGEMENT
*SICK DAY
*HYPOGLYCEMIA MOTION
* HYPERGYCEMIA