Nur 105Adult Health I
DIABETES MELLITUSJackie C. Williams, RN-C, MSN
Shelton State Community College
DEFINITIONDIABETES 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 MellitusPathophysiology
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 MellitusTypes
Type 1 - IDDM little to no insulin
produced 20-30% hereditary Ketoacidosis
Gestational overweight; risk for
Type 2
Type 2 - NIDDM some insulin
produced 90% hereditary
Other types include Secondary Diabetes : Genetic defect beta cell
or insulin Disease of exocrine
pancreas Drug or chemical
induced Infections-pancreatitits Others-steroids,
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 MellitusClinical Manifestation
Hyperglycemia Three P’s -
Polyuria
Polyphagia
Polydispsia
Gradual Onset
Hypoglycemia Weak, diaphoretic,
sweat, pallor, tremors, nervous, hungry, diplopia, confusion, aphasia, vertigo, convulsions
Treatment - OJ with sugar, or IV glucose
Sudden onset
Hyperglycemia - Clinical Manifestations
Three P’s – polyuria, polydypsia,
polyphagia Glycosuria Dehydration Hypotension Mental Changes
Fever Hypokalemia Hyponatremia Seizure Coma
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 HypoglcemiasKey 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 MellitusDiet
American Diabetic Association
Food groups/ exchanges
Carbohydrates - 60%
Fats - 30% Protein - 12-20%
Diabetes - Monitoring Glucose Levels
Urine - Ketones
FSBS
Wear ID Bracelet
Diabetes - TreatmentExercise
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 care
Proper Eye Exam
Proper diet and fluids
Diabetic Neuropathy
Diabetic Retinopathy
Diabetic Nephropathy
Diabetic gastroparesis
Diabetes MellitusComplications
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 – KetoacidosisTreatment
Patent airway Suctioning Cardiac monitoring Vital Signs Central venous
pressure Blood work – ABG,
BS, chemistry panel
Administration of Na Bicarb
Foley – monitor urinary output
I & O Frequent
Repositioning
Complication – HHNCHyperosmolar Hyperglycemic
Non-Ketotic Coma Fluid moves from
inside to outside cell vausing diuresis and loss of Na+ and K+
Treatment - Give insulin and correct fluid and electrolytes imbalance
Signs and Symptoms Hypotension Mental changes Dehydration Hypokalemia Hyponatremia
Life Threatening!!!
Chronic Complications of Diabetes
Cardiovascular disease Cerebrovascular disease Retinopathy (vision) problems Diabetic neuropathy Diabetic nephropathy Male erectile dysfunction
Diabetes MellitusNursing 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:MonitoringFluid therapy: to rehydrate the client and restore normal blood glucose levels within 36 to 72 hrContinuing 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 MellitusSummary
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.