CASE STUDY OF DM

Diabetes mellitusis a condition in which the pancreas no longer produces enough insulin or
cells stop responding to the insulin that is produced, so that glucose in the blood cannot be
absorbed into the cells of the body. Symptoms include frequent urination, lethargy,
excessive thirst, and hunger. The treatment includes changes in diet, oral medications,
and in some cases, daily injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or adult-
onset diabetes, and this form of diabetes occurs most often in people who are overweight
and who do not exercise. Type II is considered a milder form of diabetes because of its
slow onset (sometimes developing over the course of several years) and because it
usually can be controlled with diet and oral medication. The consequences of
uncontrolled and untreated Type II diabetes, however, are the just as serious as those for
Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat
misleading. Many people with Type II diabetes can control the condition with diet and
oral medications, however, insulin injections are sometimes necessary if treatment with
diet and oral medication is not working.

The causes of diabetes mellitus are unclear, however, there seem to be both hereditary
(genetic factors passed on in families) and environmental factors involved. Research has
shown that some people who develop diabetes have common genetic markers. In Type I
diabetes, the immune system, the body’s defense system against infection, is believed to
be triggered by a virus or another microorganism that destroys cells in the pancreas that
produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a
role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells have
become resistant to the insulin produced and it may not work as effectively. Symptoms of
Type II diabetes can begin so gradually that a person may not know that he or she has it.
Early signs are lethargy, extreme thirst, and frequent urination. Other symptoms may
include sudden weight loss, slow wound healing, urinary tract infections, gum disease, or
blurred vision. It is not unusual for Type II diabetes to be detected while a patient is
seeing a doctor about another health concern that is actually being caused by the yet
undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include people
who:

• are obese (more than 20% above their ideal body weight)
• have a relative with diabetes mellitus
• belong to a high-risk ethnic population (African-American, Native American,
Hispanic, or Native Hawaiian)
• have been diagnosed with gestational diabetes or have delivered a baby weighing
more than 9 lbs (4 kg)
• have high blood pressure (140/90 mmHg or above)
 • have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL
and/or a triglyceride level greater than or equal to 250 mg/dL
• have had impaired glucose tolerance or impaired fasting glucose on previous testing

Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle
changes. It is best managed with a team approach to empower the client to successfully
manage the disease. As part of the team the, the nurse plans, organizes, and coordinates
care among the various health disciplines involved; provides care and education and
promotes the client’s health and well being. Diabetes is a major public health worldwide.
Its complications cause many devastating health problems.

ANATOMY AND PHYSIOLOGY:

Every cell in the human body needs energy in order to function. The body’s primary
energy source is glucose, a simple sugar resulting from the digestion of foods containing
carbohydrates (sugars and starches). Glucose from the digested food circulates in the
blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical
produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to
a receptor site on the outside of cell and acts like a key to open a doorway into the cell
through which glucose can enter. Some of the glucose can be converted to concentrated
energy sources like glycogen or fatty acids and saved for later use. When there is not
enough insulin produced or when the doorway no longer recognizes the insulin key,
glucose stays in the blood rather entering the cells.
PATHOPHYSIOLOGY:

Image Source: www.caninsulin.com/Pathophysiology-algorithm.htm

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 (see “Symptoms” above) suggests a diagnosis of
diabetes.

• test — fasting blood glucose testing involves measuring blood

Fasting blood glucose
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. It must be repeated on
another day to confirm that it remains abnormally high (see “Criteria for
diagnosis” below).

• 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 (show figure 3). The
test is done by taking a small sample of blood from a vein or fingertip.

• — Oral glucose tolerance testing (OGTT) is the most

Oral glucose tolerance test
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 orange-
flavored). Two hours later, a second blood glucose level is measured.

Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to

screen for gestational diabetes; this requires drinking a 50 gram glucose solution with a
blood glucose level drawn one hour later. For women who have an abnormally elevated
blood glucose level, a second OGTT is performed on another day after drinking a 100
gram glucose solution. The blood glucose level is measured before, and at one, two, and
three hours after drinking the solution.

MEDICATIONS:

When diet, exercise and maintaining a healthy weight aren’t 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 can’t 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 isn’t perfect. One of its chief failings is that it doesn’t 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. You’re 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 you’re 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, it’s 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). These may not always be related to diabetes
medications, but your doctor will need to investigate all possible causes.

· Drug combinations. By combining drugs from different classes, you may be able to
control your blood sugar in several different ways. Each class of oral medication can be
combined with drugs from any other class. Most doctors prescribe two drugs in
combination, although sometimes three drugs may be prescribed. Newer medications,
such as Glucovance, which contains both glyburide and metformin, combine different
oral drugs in a single tablet.

NURSING INTERVENTIONS:

• Advice patient about the importance of an individualized meal plan in meeting

weekly weight loss goals and assist with compliance.
• Assess patients for cognitive or sensory impairments, which may interfere with
the ability to accurately administer insulin.
• Demonstrate and explain thoroughly the procedure for insulin self-injection. Help
patient to achieve mastery of technique by taking step by step approach.
• Review dosage and time of injections in relation to meals, activity, and bedtime
based on patients individualized insulin regimen.
• Instruct patient in the importance of accuracy of insulin preparation and meal
timing to avoid hypoglycemia.
• Explain the importance of exercise in maintaining or reducing weight.
• Advise patient to assess blood glucose level before strenuous activity and to eat
carbohydrate snack before exercising to avoid hypoglycemia.
• Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns,
calluses, dryness, hair distribution, pulses and deep tendon reflexes.
• Maintain skin integrity by protecting feet from breakdown.
• Advice patient who smokes to stop smoking or reduce if possible, to reduce
vasoconstriction and enhance peripheral flow.