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Diabetes mellitus is a group of metabolic diseases characterized by
increased levels of glucose in the blood (hyperglycemia) resulting
fromdefects in insulin secretion, insulin action, or both. Normally,a certain
amount of glucose circulates in the blood. The major sources of this glucose
are Absorption of ingested food in the gastrointestinal tract and Formation of
glucose by the liver from food substances.
Insulin, a hormone produced by the pancreas, controls the level of
glucose in the blood by regulating the production and storage of glucose. In
diabetes,the cells may stop respnding to insulin or the pancreas may stop
producing insulin entirely. This leads to hyperglycemia,which may results in
acute metabolic complications such as diabetes ketoacidosis (DKA) and
hyperglycemic hyperosmolar non-ketotic syndrome (HHNS).

Impact on health of population

• Sixth leading cause of death due to cardiovascular effects resulting in
atherosclerosis, coronary artery disease, and stroke
• Leading cause of end stage renal failure
• Major cause of blindness
• Most frequent cause of non-traumatic amputations
• Diabetes affects estimated 15.7 million people (10.3 million are
diagnosed; 5.4 million are undiagnosed)
• Increasing prevalence of Type 2 Diabetes in older adults and minority
groups (African American, American Indian and Hispanic populations)

1. TYPE 1 DIABETES (insulin dependent diabetes mellitus)

• About 5% to 10% of diabetic patients have type 1diabetes. Beta
cells of the pancreas that normally produce insulin are destroyed
by an autoimmune process. Insulin injections are needed to
control the blood glucose level.
• Type 1 diabetes has a sudden onset, usually before the age of 30
• Factors are contribute to beta cell destruction
>Combined genetic
>Possibly environmental (viral)
• Generally accepted that a genetic susceptibility is common
underlying factor in the development of type1 diabetes.
• This genetic tendency has been found in people with certain
human leukocyte antigen (HLA) types.
• HLA refers to a cluster of genes responsible for transplantation
antigens and other immune processes.
• Specific cause
>The destruction of the beta cells results in the decreased insulin
>Unchecked glucose production by the liver and
>Fasting hyperglycemia
• In addition, glucose derived from food cannot be stored in the
liver but instead remain in the bloodstream and contributes to
postprandial (after meals) hyperglycemia
• If the concentration of glucose in the blood exceeds the renal
threshold for glucose, the kidneys may not reabsorb all the
filtered glucose; the glucose then appears in the urine
• When excess glucose is excreted in the urine, it is accompanied
by excess loss of fluid and electrolytes. This is called osmotic

1. TYPE 2 DIABETES (non-insulin dependent diabetes mellitus)

• About 90% to 95% of diabetes have type 2 diabetes it results
from a deceased sensitivity to insulin resistance or a decreased
of amount of insulin production.
• Insulin resistance
> Major defect in individuals with type 2 diabetes
>Reduced biological response to insulin
>Strong predictor of type 2 diabetes
>Closely associated with obesity
• In type 2 diabetes , these intracellular reactions are diminished ,
making insulin less effective at stimulating glucose uptake by
the tissues and at regulating glucose release by the liver
• Increase amounts of insulin must be secreted to maintain the
glucose level at a normal. If the beta cells cannot keep up with
the increased demand for insulin, the glucose level rises and
type2 diabetes develops.
• Uncontrolled type 2 diabetes may lead to another acute problem-
• Type 2 diabetes is first treated with diet and exercise, then oral
hypoglycemic agents as needed
• Type 2 diabetes occurs most frequently inpatients older than 30
years of age and in obese patients.

• Gestational diabetes is characterized by any degree of glucose
intolerance with onset during pregnancy (second or third
• Hyperglycemia develops during pregnancy because of the
secretions of the placental hormones, which causes insulin
• It occurs in women 25 years of age or older, women younger than
25 years of age who are obese , women with a family history of
diabetes in first degree relatives , or members of certain ethnic
racial groups.


 “3 Ps”
>Polyuria( increase urination)
>Polydipsia(increase thirst)
>Polyphagia(increase appetite)
 Fatique
 Weakness
 Sudden vision changes
 Tingling or numbness in hands or feet
 Dry skin
 Skin lesions or wounds that are slow to heal
 Recurrent infection
 Onset of type 1 diabetes may be associated with nausea, vomiting, or
stomach pains.
 Type 2 diabetes results from a slow(over years), progressive glucose
intolerance and result in long term complications if diabetes goes
undetected for many years (eye disease, peripheral neuropathy,
peripheral vascular disease). Complication may have developed the
actual diagnosis is made.
 Sign and symptoms of DKA include abdominal pain, nausea ,vomiting,
hyperventilation and fruity breath odor. Untreated DKA may result in
altered level of consciousness, coma and death.

Insulin is secreted by beta cells, which are one of four types of cells
in the islets of Langerhans in the pancreas. Insulin is an anabolic, or storage,
hormone. When a person eats a meal, insulin secretion increases and moves
glucose from the blood into the muscle, liver, and fat cells. In those cells,
• Transport and metabolizes glucose for energy
• Stimulates storage of glucose in the liver and muscle (in the form of
• Signals the liver to stop the release of glucose
• Enhances the storage of dietary fat in adipose tissue
• Accelerates transport of amino acids (derived from dietary protein)
into cells

Insulin also inhibits the breakdown of stored glucose, protein, and fat.
During fasting periods (between meals and overnight), the pancreas
continuously releases a small amount of insulin (basal insulin); another
pancreatic hormone called glucagon (secreted by th alpha cells of the islets
of Langerhans) is released when blood glucose levels decrease and
stimulates the liver to release storage glucose. The insulin and glucagon
together maintain a constant level of glucose in the blood by stimulating the
release of glucose from the liver.
Initially, the liver produces glucose through the breakdown of
glycogen (glycogenolysis). After 8 to 12 hours without food, the liver forms
glucose from the breakdown of noncarbohydrate substances, including
amino acids (gluconeogenesis).

The list of diagnostic tests mentioned in various sources as used in
the diagnosis of Diabetes includes:
• Physical Examination
• Urine sugar test
• Urine ketones test
• Oral Glucose Tolerance Test (OGTT) - also called "glucose challenge"
• Blood glucose tests
○ Fasting plasma glucose (FPG)
○ Random plasma glucose
• C-peptide blood test
• Insulin level blood test
• Self-managed blood glucose testing
○ Finger prick blood drop blood glucose tests
○ Urine glucose home testing
○ Urine ketone home testing
• Type 1 diabetes antibody tests
○ Glutamic Acid Decarboxylase (GAD) antibody tests
○ Islet cell antibody (ICA) tests
○ Insulin antibody tests
• Tests for conditions related to Type 1 diabetes
○ TSH blood test - tests thyroid function
○ Vitamin B12 blood test - test for pernicious anemia and other
digestive problems
• Tests for ongoing monitoring of diabetes control:
○ HbA1c blood test - an average blood sugar measure over about 3
○ Fructosamine blood test - an average blood sugar measure over
about 2 weeks
• Tests to detect initially and then regularly screen for diabetes
○ Lipids and cholesterol - used to test risks of heart disease from
○ Blood pressure tests
○ Eye tests
○ Foot tests
○ Urine protein test - tests for kidney problems.
○ Microalbumin urine test - also called "microalbuminurea" test;
detects early kidney problems.

 The main goal of treatment is to normalize insulin activity and blood
glucose levels to reduce the development of vascular and neuropathic
 The therapeutic goal within each type of diabetes is to achieve normal
blood glucose levels (euglycemia) without hypoglycemia and without
seriously disrupting the usual activities.
 There are five components of management for diabetes: nutrition,
exercise, monitoring, pharmacologic therapy, and education.
 Primary treatment of type 1 diabetes is insulin
 Primary treatment of type 2 diabetes is weight loss.
 Exercise is important in enhancing the effectiveness of insulin.
 Use oral hypoglycemic agents if diet and exercise are not successful in
controlling blood glucose levels. Insulin injections may be used in
acute situations.

Maintaining Fluid and Electrolyte Balance
 Measure intake and output
 Administer intravenous fluids and electrolytes as ordered
 Encourage fluid intake
 Measure serum electrolytes ( sodium, potassium) and monitor closely
 Monitor vital signs to detect hydration: tachycardia
Improving Nutritional intake
 Plan the diet with glucose control as the primary goal
 Take into consideration patient’s lifestyle, cultural background, activity
level and food preferences
 Encourage patient to eat full meals and snacks as per diabetic diet
 Make arrangement for extra snacks before increased physical activity
 Ensure that insulin orders are altered as needed for delays in eating
Reducing anxiety
 Provide emotional support
 Clear up misconception with patients
 Assist patient and family to focus on learning self care behaviors
 Positive reinforcement
Monitoring and managing potential complication
Teaching patient about self care
 Teach preventive behaviors for long term complication and patient
survival skill
 Provide special equipment for instruction on diabetic survival skills
 Tailor information
 Instruct family
 Recommends follow up education; physical impairments
 Eating habits, relationship of food and insulin meal plan
 Follow up education; management skills
 Exercise is extremely important because of its effects on lowering of
blood glucose levels
 Exercise is useful in losing weight and maintaining a feeling of well
 Exercise alters blood lipids, increasing levels of high density
lipoproteins and decreasing total cholesterol and triglyceride level
Pharmacologic therapy
• Insulin replacement therapy (a must)
• Insulin + Oral hypoglycemic agents (sometimes)
• Oral hypoglycemic agents