Diabetes Mellitus

Definition: metabolic disorder

characterized by hyperglycemia due to
an absolute or relative lack of insulin or
to a cellular resistance to insulin
Major classifications
1. Type 1 Diabetes
2. Type 2 Diabetes

Diabetes Mellitus
Impact on health of American
population
1. Sixth leading cause of death due to
cardiovascular effects resulting in atherosclerosis,
coronary artery disease, and stroke
2. Leading cause of end stage renal failure
3. Major cause of blindness
4. Most frequent cause of non-traumatic
amputations

Diabetes Mellitus
5. Diabetes affects estimated 15.7 million
people (10.3 million are diagnosed; 5.4
million are undiagnosed)
6. Increasing prevalence of Type 2 Diabetes
in older adults and minority groups (African
American, American Indian and Hispanic
populations)
7. Estimated 11 % of older U. S. population
(65 74) have diabetes

Diabetes Mellitus
Diabetes Type 1
Definition
1. Metabolic condition in which the beta cells of
pancreas no longer produce insulin; characterized
by hyperglycemia, breakdown of body fats and
protein and development of ketosis
2. Accounts for 5 10 % of cases of diabetes; most
often occurs in childhood or adolescence
3. Formerly called Juvenile-onset diabetes or
insulin-dependent diabetes (IDDM)

Diabetes Mellitus
Pathophysiology
1. Autoimmune reaction in which the beta cells that
produce insulin are destroyed
2. Alpha cells produce excess glucagons causing
hyperglycemia
Risk Factors
1. Genetic predisposition for increased susceptibility;
HLA linkage
2. Environmental triggers stimulate an autoimmune
response
a. Viral infections (mumps, rubella, coxsackievirus B4)
b. Chemical toxins

Diabetes Mellitus
Manifestations
1. Process of beta cell destruction occurs
slowly; hyperglycemia occurs when 80
90% is destroyed; often trigger
stressor event (e. g. illness)

Diabetes Mellitus
2. Hyperglycemia leads to
a. Polyuria (hyperglycemia acts as osmotic diuretic)
b. Glycosuria (renal threshold for glucose: 180
mg/dL)
c. Polydipsia (thirst from dehydration from polyuria)
d. Polyphagia (hunger and eats more since cell
cannot utilize glucose)
e. Weight loss (body breaking down fat and protein
to restore energy source
f. Malaise and fatigue (from decrease in energy)
g. Blurred vision (swelling of lenses from osmotic
effects)

Diabetes Mellitus
Diagnosis
Patient is symptomatic plus
Casual plasma glucose (non-fasting) is 200
mg/dl OR
Fasting plasma glucose of 126 mg/dl or higher
OR
Two hour plasma glucose level of 200 mg/dl or
greater during an oral glucose tolerance test

Diabetes Mellitus
Diabetic Ketoacidosis (DKA)
1. Results from breakdown of fat and overproduction
of ketones by the liver and loss of bicarbonate
2. Occurs when Diabetes Type 1 is undiagnosed or
known diabetic has increased energy needs, when
under physical or emotional stress or fails to take
insulin
1.

3.

Mortality as high as 14%

Pathophysiology
a. Hypersomolarity (hyperglycemia, dehydration)
b. Metabolic acidosis (accumulation of ketones)
c. Fluid and electrolyte imbalance (from osmotic
diuresis)

Diabetes Mellitus
Diagnostic tests
a. Blood glucose greater than 250 mg/dL
b. Blood pH less than 7.3
c. Blood bicarbonate less than 15 mEq/L
d. Ketones present in blood
e. Ketones and glucose present in urine
f. Electrolyte abnormalities (Na, K, Cl)
G. serum osmolality < 350 mosm/kg (normal
280-300)

Diabetes Mellitus
DKA
Signs and symptoms
Kussmals respirations
Blow off carbon dioxide to reverse acidosis

Fruity breath
Nausea/ abdominal pain
Dehydration
Lethargy
Coma
Polydipsia, polyuria, polyphagia

Diabetes Mellitus
Treatment
a. Requires immediate medical attention and usually
admission to hospital
B .Frequent measurement of blood glucose and treat
according to glucose levels with regular insulin (mild
ketosis, subcutaneous route; severe ketosis with
intravenous insulin administration)
c. Restore fluid balance: initially 0.9% saline at 500
1000 mL/hr.; regulate fluids according to client
status; when blood glucose is 250 mg/dL add
dextrose to intravenous solutions

Diabetes Mellitus
DKA
d.Correct electrolyte imbalance: client often is
initially hyperkalemic
As patient is rehydrated and potassium in pushed back
into the cell they become hypokalemic
Monitor K levels

e. Monitor cardiac rhythm since hypokalemia puts

client at risk for dysrrhythmias
f. Treat underlying condition precipitating DKA
G. Acidosis is corrected with fluid and insulin
therapy and rarely needs bicarb

Diabetes Mellitus
Diabetes Type 2
A. Definition: condition of fasting
hyperglycemia occurring despite
availability of bodys own insulin
B. Was known as non-insulin
dependent diabetes or adult onset
diabetes
Both are misnomers, it can be found in
children and type II DM may require insulin

Diabetes Mellitus
Pathophysiology
1. Sufficient insulin production to
prevent DKA; but insufficient to lower
blood glucose through uptake of
glucose by muscle and fat cells
2. Cellular resistance to insulin
increased by obesity, inactivity, illness,
age, some medications

Diabetes Mellitus
Risk Factors
1. History of diabetes in parents or siblings; no
HLA
2. Obesity (especially of upper body)
3. Physical inactivity
4. Race/ethnicity: African American, Hispanic, or
American Indian origin
5. Women: history of gestational diabetes,
polycystic ovary syndrome, delivered baby with birth
weight > 9 pounds
6. Clients with hypertension; HDL cholesterol < 35
mg/dL, and/or triglyceride level > 250 mg/dl.

Diabetes Mellitus
Syndrome X or Metabolic Syndrome
Chronic, low grade inflammatory process
Gives rise to diabetes type 2, ischemic heart
disease, left ventricular hypertrophy
Group of disorders with insulin resistance as the
main feature
Includes

Obesity especially around the waist and abdomen

Low levels of physical activity
High blood pressure
Increased blood cholesterol (high LDL, low HDL, high
triglycerides

Diabetes Mellitus
Manifestations
1. Client usually unaware of diabetes
a. Discovers diabetes when seeking health care for
another concern
b. Most cases arent diagnosed for 5-6 years after
the development of the disease
c. Usually does not experience weight loss

Diabetes Mellitus
2. Possible symptoms or concerns
a. Hyperglycemia (not as severe as with
Type 1)
b. Polyuria
c. Polydipsia
d. Blurred vision
e. Fatigue
f. Paresthesias (numbness in extremities)
g. Skin Infections

Diabetes Mellitus
Hypersomolar Hyperglycemic Nonketotic
Syndrome (HHNS)
1. Potential complication of Diabetes Type 2
2. Life threatening medical emergency, high
mortality rate, as high as 50%
3. Enough insulin is secreted to prevent
ketosis, but not enough to prevent
hyperglycemia
4. High blood sugar causes an extreme
diuresis with severe electrolyte and fluid
loss

 Characterized by
Plasma osmolarity 340 mOsm/l or greaternormal 280-300
Blood glucose severely elevated, 800-1000
Altered level of consciousness

Diabetes Mellitus
4.
Precipitating factors
a. Infection (most common)
pneumonia

b. Therapeutic agent or procedure

c. Acute or chronic illness

5.

MI
Stroke
Pancreatitis
pregnancy

Slow onset 1 14 days

Diabetes Mellitus
Pathophysiology
a. Hyperglycemia leads to increased urine output and
dehydration
b. Kidneys retain glucose; glucose and sodium rise
c. Severe hyperosmolar state develops leading to
brain cell shrinkage
Manifestations
a. Altered level of consciousness (lethargy to coma)
b. Neurological deficits: hyperthermia, motor and
sensory impairment, seizures
c. Dehydration: dry skin and mucous membranes,
extreme thirst, tachycardia, polyuria, hypotension

Diabetes Mellitus
Treatment
a. Usually admitted to intensive care unit of
hospital for care since client is in life-threatening
condition: unresponsive, may be on ventilator, has
nasogastric suction
b. Correct fluid and electrolyte imbalances giving
isotonic or colloid solutions and correct potassium
deficits
c. Lower glucose with regular insulin until glucose
level drops to 250 mg/dL
Monitor for renal failure
d. Treat underlying condition

Diabetes Mellitus
Complications of Diabetes
A. Alterations in blood sugars: hyperglycemia and hypoglycemia
B. Macrocirculation (large blood vessels)
1. Atherosclerosis occurs more frequently, earlier in diabetics
2. Involves coronary, peripheral, and cerebral arteries
C. Microcirculation (small blood vessels)
1. Affects basement membrane of small blood vessels and
capillaries
2. Involves tissues affecting eyes and kidneys
D. Prevention of complications
1. Managing diabetes
2. Lowering risk factors for conditions
3. Routine screening for complications
4. Implementing early treatment

Diabetes Mellitus
Complications of Diabetes: Alterations in blood sugars
A. Hyperglycemia: high blood sugar
1.DKA (mainly associated with Diabetes Type 1)
2.HHS (mainly associated with Diabetes Type 2)
3.Dawn phenomenon: rise in blood sugar between 4 am and 8
am, not associated with hypoglycemia
Glucose released from the liver in the early AM secondary to
growth hormones
Altering the time and dose of the insulin (NPH or Ultralente) by 2-3
units stabilizes the blood sugar

Diabetes Mellitus
4. Somogyi effect: combination of
hypoglycemia during night with a
rebound morning hyperglycemia that
may lead to insulin resistance for 12 to
48 hours

Diabetes Mellitus
B. Hypoglycemia (insulin reaction,
insulin shock, the lows): low blood
sugar
1.Mismatch between insulin dose,
carbohydrate availability and exercise
2.May be affected by intake of alcohol,
certain medications

Diabetes Mellitus
Specific manifestations
a. Cool, clammy skin
b. Rapid heartbeat
c. Hunger
d. Nervousness, tremor
e. Faintness, dizziness
f. Unsteady gait, slurred and/or incoherent speech
g. Vision changes
h. Seizures, coma
5. Severe hypoglycemia can result in death
6. Clients taking medications, such as beta-adrenergic blockers
may not experience manifestations associated with autonomic
nervous system
7. Hypoglycemia unawareness: clients with Diabetes Type 1 for 4
or 5 years or more may develop severe hypoglycemia without
symptoms which can delay treatment

Diabetes Mellitus
Treatment for mild hypoglycemia
a. Immediate treatment: client should take 15 gm of
rapid-acting sugar (half cup of fruit juice; 8 oz of
skim milk, 3 glucose tablets, 3 life savers
b. 15/15 rule: wait 15 minutes and monitor blood
glucose; if still low, client should eat another 15 gm
of sugar
c. Continue until blood glucose level has returned
to normal
d. Client should contact medical care provider if
hypoglycemia occurs more that 2 or 3 times per
week

Diabetes Mellitus
Treatment for severe hypoglycemia is often
hospitalization
a. Client is unresponsive, has seizures, or has altered
behavior; blood glucose level is less than 50 mg/dL
b. If client is conscious and alert, administer 15 gm of
sugar
c. If client is not alert, administer
1. 25 % 50% solution of glucose intravenously,
followed by infusion of 5% dextrose in water
2. Glucagon 1 mg by subcutaneous, intramuscular,
or intravenous route; follow with oral or intravenous
carbohydrate
d. Monitor client response physically and also blood
glucose level

Diabetes Mellitus
Complications Affecting Cardiovascular System,
Vision, and Kidney Function
A. Coronary Artery Disease
1. Major risk of myocardial infarction in Type 2
diabetics
Increased chance of having a silent MI and delaying medical
treatment

2. Most common cause of death for diabetics (40

60%)
3. Diabetics more likely to develop Congestive
Heart Failure

Diabetes Mellitus
B. Hypertension
1. Affects 20 60 % of all diabetics
2. Increases risk for retinopathy,
nephropathy

Diabetes Mellitus
C. Stroke:
Type 2 diabetics are 2 6 times more
likely to have stroke as well as Transient
Ischemic Attacks (TIA) or mini stroke

Diabetes Mellitus
D. Peripheral Vascular Disease
1. Increased risk for Types 1 and 2
diabetics
2. Development of arterial occlusion
and thrombosis resulting in gangrene
3. Gangrene from diabetes most
common cause of non-traumatic lower
limb amputation

Diabetic Foot Ulcer

Diabetes Mellitus
Diabetic Retinopathy
1. Definition

a. Retinal changes related to diabetes

2.

3.

Hemorrhage, swelling, decreased vision

b. Leads to retinal ischemia and breakdown of blood-retinal

barrier
Leading cause of blindness ages 25 74
a. Affects almost all Type 1 diabetics after 20 years
b. Affects 60 % of Type 2 diabetics
Diabetics should be screened for retinopathy and receive
treatment (laser photocoagulation surgery) to prevent
vision loss
1.

4.

Should be sent immediately to ophthalmologist upon diagnosis

because may already have damage

Diabetics also have increased risk for cataract development

Diabetes Mellitus
Diabetic Nephropathy
1. Definition: glomerular changes in kidneys of
diabetics leading to impaired renal function
2. First indicator: microalbuminuria
3. Diabetics without treatment go on to develop
hypertension, edema, progressive renal insufficiency
a. In type 1 diabetics, 10 15 years
b. May occur soon after diagnosis with type 2
diabetes since many are undiagnosed for years
4. Most common cause of end-stage renal failure in
U.S.
5. Kimmelstiel-Wilson syndrome:
glomerulosclerosis associated with diabetes

Diabetes Mellitus
Male erectile dysfunction
Half of all diabetic men have erectile
dysfunction

Diabetes Mellitus
Collaborative Care
A. Based on research from 10-year study of Type 1
diabetics conducted by NIH focus is on keeping
blood glucose levels as close to normal by active
management interventions; complications were
reduced by 60%
B. Treatment interventions are maintained through
1. Medications
2. Dietary management
3. Exercise
C. Management of diabetes with pancreatic transplant,
pancreatic cell or Beta cell transplant is in
investigative stage

Diabetes Mellitus
Other Complications from Diabetes
A. Increased susceptibility to infection
1. Predisposition is combined effect of other
complications
2. Normal inflammatory response is
diminished
3. Slower than normal healing
B. Periodontal disease
C. Foot ulcers and infections: predisposition
is combined effect of other complications

Diabetes Mellitus
Diagnostic tests to monitor diabetes management
1. Fasting Blood Glucose (normal: 70 110 mg/dL)
2. Glycosylated hemoglobin (c) (Hemoglobin A1C)
a. Considered elevated if values above 7%
b. Blood test analyzes excess glucose attached
to hemoglobin. Since rbc lives about 120 days
gives an average of the blood glucose over
previous 2 to 3 months
Not a fasting test, can be drawn any time of the day
% of glycated (glucose attached) hemoglobin
measures how much glucose has been in the
bloodstream for the past 3 months

Diabetes Mellitus
3. Urine glucose and ketone levels (part
of routine urinalysis)
a.
Glucose in urine indicates hyperglycemia
(renal threshold is usually 180 mg/dL)
b. Presence of ketones indicates fat breakdown,
indicator of DKA; ketones may be present if
person not eating

4. Urine albumin (part of routine urinalysis)

a. If albumin present, indicates need for
workup for nephropathy
b. Typical order is creatinine clearance
testing

Diabetes Mellitus
5.Cholesterol and Triglyceride levels
a. Recommendations
1. LDL < 100 mg/dl
2. HDL > 45 mg/dL
3. Triglycerides < 150 mg/dL
b. Monitor risk for atherosclerosis and
cardiovascular complications
6.Serum electrolytes in clients with DKA or
HHNS

Diabetes Mellitus
A.

2.

Medications
Insulin
1. Sources: standard practice is use of human insulin
prepared by alteration of pork insulin or recombinant DNA
therapy
Clients who need insulin as therapy:
a. All type 1 diabetics since their bodies essentially no longer
produce insulin
b. Some Type 2 diabetics, if oral medications are not
adequate for control (both oral medications and insulin may be
needed)
c. Diabetics enduring stressor situations such as surgery,
corticosteroid therapy, infections, treatment for DKA, HHNS
d. Women with gestational diabetes who are not adequately
controlled with diet
e. Some clients receiving high caloric feedings including
tube feedings or parenteral nutrition

Diabetes Mellitus
Injection sites
Abdominal areas is the most preferred
because of rapid absorption
Do not aspirate insulin injections
Administration covered in the lab

Diabetes Mellitus

Diabetes Injection Sites

Diabetes Mellitus
When rapid acting or short acting insulin is
mixed with longer acting insulin, draw the
short acting insulin into the syringe first.
Prevents contamination of the shorter acting
insulin with the longer acting insulin
Draw up clear, then cloudy
Insuling glargine (Lantus) should not be
mixed with any other insulin

Diabetes Mellitus
Mixing insulin

Diabetes Mellitus
Alternative insulin administration
Insulin pump
Continuous subcutaneous infusion of a basal
dose with increases at meal times

Implanted pumps
Implanted into the peritoneal cavity

Inhaled insulin
Under development

Insulin Pump

Internal Insulin Pump

Diabetes Mellitus
Oral Hypoglycemic Agents
1. Used to treat Diabetes Type 2
2. Client must also maintain prescribed diet and
exercise program; monitor blood glucose levels
3. Not used with pregnant or lactating women
4. Several different oral hypoglycemic agents and
insulin may be prescribed for the client
5. Specific drug interactions may affect the blood
glucose levels
6. Must have some functioning beta cells

Diabetes Mellitus
Classifications and action
a.Sulfonylureas
1. Action: Stimulates pancreatic cells to
secrete more insulin and increases
sensitivity of peripheral tissues to insulin
2. Used: to treat non-obese Type 2
diabetics
3. Example: Glipizide (Glucotrol),
Chlorpropamide (Diabinese), Tolazamide
(Tolinase)

Diabetes Mellitus
b.Meglitinides
1. Action: stimulates pancreatic cells to
secret more insulin
2. Taken just before meals, rapid onset,
limited duration of action
3. Major adverse effects is hypoglycemia
4. Used in non-obese diabetics
5. Example: Repaglinide (Prandin),
Nateglinide (Starlix)

Diabetes Mellitus
c.Biguanides
1. Action: decreases overproduction of
glucose by liver and makes insulin more
effective in peripheral tissues
2. Used in obese diabetics
3. Does not stimulate insulin release
4. Metabolized by the kidney, do not use
with renal patients
5. Example: Metformin (Glucophage

Diabetes Mellitus
d. Alpha-glucoside Inhibitors
1. Action: Slow carbohydrate digestion
and delay rate of glucose absorption
2. Take with first bite of the meal or 15
min. after
3. Adjunct to diet to decrease blood
glucose levels
4. Example: Acarbose (Precose),
Miglitol (Glyset)

Diabetes Mellitus
Thizaolidinediones (Glitazones)
1. Action: Sensitizes peripheral tissues
to insulin
2. Used in obese diabetics
3. Inhibits glucose production
4. Improves sensitivity to insulin in
muscle, and fat tissue
5. Example: Rosiglitazone (Avandia),
Pioglitazone (Actos)

Diabetes Mellitus
Patients with Type 2 DM who are obese
have insulin resistance, they produce
enough insulin
Should use Glucophage, Actos or Avandia
Enhances insulin secretion in tissue, but
does not increase amount of insulin
secreted

Diabetes Mellitus
Patients with Type 2 DM who are thin
do not produce enough insulin, they
are not insulin resistant
Need sulfonylurea agents like Diabinese,
Tolinase, Glucotrol, Diabeta

Diabetes Mellitus
Role of Diet in Diabetic Management
A. Goals for diabetic therapy include
1. Maintain as near-normal blood
glucose levels as possible with balance
of food with medications
2. Obtain optimal serum lipid levels
3. Provide adequate calories to attain
or maintain reasonable weight

Diabetes Mellitus
B.
Diet Composition
1. Carbohydrates: 60 70% of daily diet
Carbohydrates convert quickly to sugars
Advice patient to consume a similar amount of carbs at
each meal
Medications can work on a consistent glucose response
from foods

2. Protein: 15 20% of daily diet

3. Fats: No more than 10% of total calories
from saturated fats

Diabetes Mellitus
4. Fiber: 20 to 35 grams/day; promotes
intestinal motility and gives feeling of
fullness
5. Sodium: recommended intake 1000 mg
per 1000 kcal
6. Sweeteners approved by FDA instead of
refined sugars
7. Limited use of alcohol: potential
hypoglycemic effect of insulin and oral
hypoglycemics

Diabetes Mellitus
Diet
Look for more dietary information online at
http://www.diabetes.org/nutrition-andreceipes/nutrition/overview.jsp

Diabetes Mellitus
Care of diabetic older clients
A. 40% of all clients with diabetes are over age of
65
B. Need to include spouse, members of family in
teaching who may assist with client meeting medical
needs
C. Diet changes may be difficult to implement since
client has established eating habits
D. Exercise programs may need adjustment to meet
individuals abilities (such as physical limitations
from other chronic illnesses)
Obesity worsens diabetes
Minimum of 30 minutes of moderate exercise like walking or
swimming most days of the week

Diabetes Mellitus
E. Individual reluctance to accept
assistance to deal with chronic illness,
assist with hygiene
F. Limited assets for medications,
supplies, dietary
G. Visual deficits or learning
challenges to learn insulin
administration, blood glucose
monitoring

Diabetes Mellitus
Nursing Care
A. Assessment, planning, implementation with
client according to type and stage of diabetes
B. Prevention, assessment and treatment of
complications through client self-management and
keeping appointments for medical care
C. Client and family teaching for diabetes
management
D. Health promotion includes education of healthy
life style, lowering risks for developing diabetes for
all clients
E. Blood glucose screening at 3 year intervals
starting at age 45 for persons in high risk groups

Diabetes Mellitus
Common Nursing Diagnoses and Specific Teaching Interventions
A. Risk for impaired skin integrity: Proper foot care
1. Daily inspection of feet
2. Checking temperature of any water before washing feet
3. Need for lubricating cream after drying but not between
toes
4. Patients should be followed by a podiatrist
5. Early reporting of any wounds or blisters
B. Risk for infection
1. Frequent hand washing
2. Early recognition of signs of infection and seeking
treatment
3. Meticulous skin care
4. Regular dental examinations and consistent oral hygiene
care

Diabetes Mellitus
C.
Risk for injury: Prevention of accidents,
falls and burns
D.
Sexual dysfunction
1. Effects of high blood sugar on sexual
functioning,
2. Resources for treatment of impotence,
sexual dysfunction
E.Ineffective coping
1. Assisting clients with problem-solving
strategies for specific concerns

Diabetes Mellitus
2. Providing information about diabetic
resources, community education
programs, and support groups
3. Utilizing any client contact as
opportunity to review coping status
and reinforce proper diabetes
management and complication
prevention