I.

INTRODUCTION Diabetes Mellitus (DM) is a chronic disease, which can occur when there is a lack of insulin secretion or when the body cannot effectively use insulin (a hormone produced by the pancreas that lowers glucose in the blood thus, regulating blood sugar). A common effect of uncontrolled diabetes due to the absence or insufficient production of insulin is an increased concentration of glucose in the blood (hyperglycemia) and may further lead to serious damage to the different body systems, especially the nerves and blood vessels. There are two major types of DM: TYPE 1 TYPE 2

Commonly known as: Insulin- Commonly known as: Non-Insulin Dependent Diabetes Mellitus Dependent Diabetes Mellitus (IDDM) (NIDDM) Due to Heredity (Hereditary). Lifestyle-related (such as It may also result from excessive body weight and progressive failure of the physical inactivity)
pancreatic beta cells.

Onset: Juvenile or childhood onset; Onset: Adult onset However, it can occur in an older individual due to destruction of the pancreas by alcohol, disease or removal by surgery. Pathologic Etiology: Pathologic Etiology: Absolute deficiency (No insulin Lack/ inadequate insulin produced) Insulin resistance

Main Treatment: administration of Insulin Acute complication: (Diabetic Ketoacidosis)

daily Main Treatment: OHA (Oral Hypoglycemic Agent) DKA Acute complication: HHNK (Hyperglycemic Hyperosmolar Nonketotic Coma)

DM is also associated with the following: Gestational diabetes, which is hyperglycemia that is recognized during pregnancy. Impaired glucose tolerance (IGT) and impaired fasting glycemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes, although this is not inevitable. Prediabetes is a common condition related to diabetes. In people with prediabetes, the blood sugar level is higher than normal but not yet high enough to be considered diagnostic of diabetes. Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes. * Key Facts (According to World Health Organization): 346 million people worldwide have diabetes. In 2004, an estimated 3.4 million people died from consequences of high blood sugar. More than 80% of diabetes deaths occur in low- and middle-income countries. WHO projects that diabetes death will double between 2005 and 2030. Diabetes affects approximately 26 million people in the United States, while another 79 million gave pre-diabetes. In addition, an estimated additional 7 million people in the United States have diabetes and don't even know it. Diabetes was the 7th leading cause of death in the United States listed on death certificates in 2007.

Globally, as of 2010, an estimated 285 million people had diabetes, with type 2 making up about 90% of the cases

CAUSE The exact cause is still unknown. However, there are certain factors that that can lead to DM. These are the following: Stress Heredity = due to the diabetogenic gene Lifestyle, particularly Obesity Auto-immune Ethnicity Age = Increasing age is a significant risk factor for type 2 diabetes. Risk begins to rise significantly at about age 45 years, and rises considerably after age 65 years. SIGNS AND SYMPTOMS Generally, the clinical assessment of diabetes mellitus includes: 3 CARDINAL SIGNS: - Polyuria = also known as hyperosmolar diuresis, which causes an increased urine output. - Polydipsia = also known as hyperosmolar dehydration causing excessive thirst. - Polyphagia = also known as cellular starvation. DM suppresses the satiety center causing increased hunger. ASSOCIATED SIGNS: - Weight Loss = due to prolonged cellular starvation. - Nausea and Vomiting - Slow healing wound = due to poor circulation which is conducive for bacterial growth. - Warm & dry skin - Fatigue - Syncope - Changes in vision - Altered mental status These symptoms of untreated diabetes are related to elevated blood sugar levels, and loss of glucose in the urine. The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and

protein. A relative or absolute insulin deficiency eventually leads to weight loss despite an increase in appetite. Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated glucose levels can lead to lethargy and coma. Metabolic Syndrome Syndrome X It is a set of abnormalities in which insulin-resistant diabetes (Type 2 DM) is almost always present along with hypertension, increased serum lipids, increased LDL but decreased HDL cholesterol, elevated triglycerides, central obesity, as well as abnormal blood clotting and inflammatory responses. COMPLICATIONS Diabetes Mellitus leads to the following complications which can either have microvascular or macrovascular effects. Microvascular effects: - Diabetic nephropathy= DM is the leading cause of endstage renal disease which requires dialysis or transplantation. Its hallmark is albumin excretion. - Diabetic retinopathy = this is a progressive impairment in retinal circulation and its first sign is blurring of vision. It can lead to blindness. - Diabetic neuropathy = this can lead to non-traumatic amputations of the lower extremities because of foot wounds and ulcers that does not heal easily. Macrovascular effects: If these three microvascular effects continued to progress it will lead to the following: - Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Renal Diseases And as mentioned earlier, the two types of DM have acute complications like: Diabetic Ketoacidosis (DKA) this is a life-threatening complication of Type 1 DM. It is caused by under dose of insulin, illness or infection, and stress or surgery. Its clinical manifestations include Kussmauls respiration, acetone breath,

nausea & vomiting, and abdominal pain. It is treated with insulin drip, IVF rehydration and Sodium Bicarbonate. Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK) this is a complication of Type 2 DM which is manifested by severe hyperglycemia & dehydration. The treatment is the same with DKA except for giving Sodium Bicarbonate. DIAGNOSIS Early detection of these complications and implementation of appropriate treatment strategies will reduce the risk for adverse outcomes from these complications. Hence, diagnosis can be accomplished through the following: DIAGNOSTIC PROCEDURES MEASUREMENT FBS (Fasting Blood Sugar) OGTT (Oral Glucose Tolerance test): - also known as Oral Glucose Challenge Test - used for gestational DM and to confirm FBS result (esp. if it FBS result is slightly elevated to <120 mg/dL HbA1C (Glycosyliated Hgb): - this determines the percent of glucose attached to RBC for 3-4 months (90-120 days) RBS (Random Blood Sugar) NORMAL VALUES 70-110 mg/dL 110-170 mg/dL (30 mins after blood sugar test) 80-110 mg/dL (2 hours after)

<7%

70-125 mg/dL

Fasting Blood Sugar The fasting blood glucose (FBS) test is the preferred way to diagnose diabetes. It is easy to perform and convenient. After the person has fasted overnight (at least 8 hours), a single sample of blood is drawn and sent to the laboratory for analysis. This can also be done accurately using a glucose meter. A fasting plasma glucose level of more than 126 mg/dl on two or more tests, on different days indicate diabetes. A random blood glucose test can also be used to diagnose diabetes. A blood glucose level of 200 mg/dl or higher indicates diabetes. When fasting blood glucose stays above 100mg/dl,

but in the range of 100-126mg/dl, this is known as impaired fasting glucose (IFG). Oral glucose tolerance test Though not routinely used anymore, the oral glucose tolerance test (OGTT)is a gold standard for making the diagnosis of type 2 diabetes. It is still commonly used for diagnosing gestational diabetes and in conditions of prediabetes, such as polycystic ovary syndrome. With an oral glucose tolerance test, the person fasts overnight (at least eight but not more than 16 hours). Then first, the fasting plasma glucose is tested. After this test, the person receives 75 grams of glucose. (Usually, the glucose is in a sweet-tasting liquid that the person drinks.) Blood samples are taken at specific intervals to measure the blood glucose. For the test to give reliable results: The person must be in good health (not have any other illnesses, not even a cold). The person should be normally active (not lying down, for example, as an inpatient in a hospital), and The person should not be taking medicines that could affect the blood glucose. The morning of the test, the person should not smoke or drink coffee. Glucose tolerance tests may lead to one of the following diagnoses: Normal response: A person is said to have a normal response when the 2-hour glucose level is less than 140 mg/dl, and all values between 0 and 2 hours are less than 200 mg/dl. Impaired glucose tolerance: A person is said to have impaired glucose tolerance when the fasting plasma glucose is less than 126 mg/dl and the 2-hour glucose level is between 140 and 199 mg/dl. Diabetes: A person has diabetes when two diagnostic tests done on different days show that the blood glucose level is high. Gestational diabetes: A pregnant woman has gestational diabetes when she has any two of the following: a fasting plasma glucose of 92 mg/dl or more, a 1-hour glucose level of 180 mg/dl or more, or a 2-hour glucose level of 153 mg/dl, or more. II. MANAGEMENT Management of Diabetes Mellitus reflects the triad of M.A.D. which

stands for the following:

ACTIVITY

MEDICATION

DIET

Primary management goals for diabetes patients include the achieving of blood glucose levels that are as close to normal as possible and the prevention of diabetic complications. Other goals are normal growth and development, normal body weight, the avoidance of sustained hyperglycemia or symptomatic hypoglycemia, the prevention of diabetic ketoacidosis and nonketotic acidosis, and the immediate detection and treatment of long-term diabetic complications. Diet, exercise, weight control, and medications are the mainstays of diabetic care. Obesity is very common in type 2 diabetes and contributes greatly to insulin resistance. Activities/ exercises appropriate for DM patients are based on weight reduction which improves tissue sensitivity to insulin and allow its proper use by target tissues. There should be a monitoring of glucose before, during and after the exercise period. Medications vary depending on the type of diabetes the client has wherein the primary medication used in type 1 diabetes management is insulin (on which the type 1 diabetic patient is dependent for survival). Type 2 diabetic individuals frequently take oral medications although many also use insulin to improve glycemic control. A Diabetic diet includes a low calorie but high fiber diet. PREVENTION: Simple lifestyle measures have been shown to be effective in preventing or delaying the onset diabetes. One should: Achieve and maintain healthy body weight; Being physically active at least 30 minutes of regular, moderateintensity activity on most days. More activity is required for weight control;

 Eating a healthy diet of between three and five servings of fruit and vegetables a day and reduce sugar and saturated fats intake; Avoiding tobacco use smoking increases the risk of cardiovascular diseases. III. TREATMENT Diabetes treatment is highly individualized, depending on the type and severity of the diabetes. Generally, it involves lowering blood glucose and the levels of other known risk factors that damage blood vessels. And since diabetes may greatly increase the risk for heart disease and peripheral artery disease, measures to control blood pressure and cholesterol levels are an essential part of diabetes treatment as well (e.g. Tobacco use cessation). For Type 1 DM, the treatment is administration of insulin. Side effects of insulin include: Dawn phenomenon due to nocturnal release of growth hormone that antagonizes the effect of insulin and causes prebreakfast hyperglycemia. This is treated by NPH (Neutral Protamine Hagedorn). Allergic Response Somogyi phenomenon in here, there is a normal blood sugar at hours of sleep but at around 2-3 am, hypoglycemia occurs. This causes an increase of intrinsic hyperglycemic hormones that leads to rebound hyperglycemia. This is treated by decreasing the evening dose of insulin and through giving midnight snack. Hypoglycemia manifested by tremors/ tachycardia, irritability, restlessness, excessive hunger, and diaphoresis/ dizziness. Lipodystrophy hardening of subcutaneous tissues which becomes fibrous adipose tissues. To prevent this, injection sites should be rotated with a distance of 2.54 cm. apart and should not be massaged, so that there will not be a rapid absorption of insulin. Insulin is administered at room temperature. On the other hand, for Type 2 DM, the treatment includes medications particularly Oral Hypoglycemic Agents (OHA) which is the following: Alpha glucosidase inhibitor its mechanism of action is to

decrease the absorption of carbohydrates in G.I. tract. Biguanides it decreases insulin resistance. Sulfonylureas the mechanism of action is to stimulate the cells

REFERENCES: Diabetes Mellitus Managementhttp://www.health.am/db/diabetesmanagement/#ixzz23IcRngtd http://www.who.int/mediacentre/factsheets/fs312/en/index.html MedscapeReference.com. Previous contributing author: Ruchi Mathur, MD, FRCP(C) Brunner and Suddarth's Textbook of Medical Surgical Nursing

IV. HEALTH TEACHING Patient education for diabetic patients is very important for the management of the disease. With this Ive included the following in my health teaching to my client who has Type 2 diabetes: 1. Discussion of the importance of glucose monitoring. Testing blood glucose levels pre-meal and post-meal can help the client with diabetes make better food choices, based on how their bodies are responding to specific foods. Clients should be taught specific directions for obtaining an adequate blood sample and what to do with the numbers that they receive. 2. Discussion of importance of blood pressure monitoring and management, including the management and prevention of other disease processes. 3. Ive instructed the client to take the prescribed medications as well as increase self-monitoring frequency and test urine for ketones. 4. Maintain adequate fluid and caloric intake by encouraging the client to adhere to prescribed dietary modifications. Modifying eating habits, together with increasing physical activity are typically the first steps toward reducing blood sugar levels Typically, the client is prescribed a low-fat, low-cholesterol, low sodium, and high fiber diet. I encouraged her to follow consistent meal schedules and food amounts which consist of multiple servings of fruits, vegetables, whole grains, low-fat dairy products, fish, lean meats, and poultry. 5. Advising clients to follow an appropriate exercise program. Regular exercise can improve the functioning of the cardiovascular system,

improve strength and flexibility, improve lipid levels, improve glycemic control, help decrease weight, and improve quality of life and selfesteem. However, complications of diabetes need to be taken into account. Injury to patients with loss of sensation in their feet is a limitation for weight-bearing exercise. 6. Teach skin care and protection, particularly the foot area. Ive instructed the client to properly bathe, dry, and lubricate feet; inspect feet daily for redness, blisters, and ulcerations; use a mirror to check the bottoms of feet; and wear well-fitting closed toe shoes. 7. Instruct the client in the care of minor wounds; instruct client to clean wounds with soap and water, apply antibiotic ointment, and notify health care provider if signs of infection occur. 8. Advising the client to avoid smoking and alcohol. 9. Teach the client to avoid nephrotoxic substances, prevent or treat urinary tract infections immediately, and adjust medications as renal function changes. 10. Encourage the client to have annual opthalmologic examinations which allows for early detection and treatment of retinopathy. V. OUTCOME