Diabetes

Introduction:
A group of diseases characterized by hyperglycemia caused by defects in insulin secretion,
action, or both. 171 million in the world (WHO); one third are undiagnosed, Prevalence is
increasing

DM:
- Physical, social, and economic consequences
- A leading cause of non-traumatic amputations, blindness, and end-stage
kidney disease (ESKD).
- A leading cause of death from disease (MI, stroke, and peripheral vascular
disease).
Functions of Insulin
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 1) Transports and metabolizes glucose for energy
2) Stimulates storage of glucose in the liver and muscle as glycogen
3) Signals the liver to stop the release of glucose
4) Enhances storage of fat in adipose tissue
5) Accelerates transport of amino acids into cells
6) Inhibits the breakdown of stored glucose, protein, and fat
Classifications of Diabetes
1) Type 1 diabetes
2) Type 2 diabetes
3) Pre-diabetes, impaired glucose tolerance (IGT) or impaired fasting glucose
(IFG)
4) Gestational diabetes (usually on 2nd and 3rd trimester)
5) Diabetes associated with other conditions (e.g., pancreatic diseases,
hormonal abnormalities, medications such as corticosteroids )
Type 1 Diabetes
a) Beta cells (Insulin producing) destroyed by an autoimmune process
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 b) Requires insulin (little or no insulin is produced)
c) Onset is acute and usually before the age of 30 y
d) Represent 5-10% of diabetic patients.

If glucose > 80 to 200 mg/dL (9.9 to 11.1 mmol/L), the kidneys may not reabsorb all of the

filtered glucose; the glucose then appears in the urine called glycosuria.

Type 2 Diabetes
a) Decreased sensitivity to insulin (insulin resistance) and impaired beta cell
function result in decreased insulin production
b) Represent 90% to 95% of person with diabetes.
c) Onset over 30 years age, increasing with obesity
d) Slow, progressive glucose intolerance
e) Treated initially with diet and exercise

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f) Oral hypoglycemic agents initially may need to convert to insulin or use both

Pathogenesis of Type 2 Diabetes

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Question
Is the following statement true or false?
Type 1 diabetes is treated initially with diet and exercise.

Gestational Diabetes
a) Glucose intolerance, onset during pregnancy.
b) Secretion of placental hormones causes insulin resistance.
c) Occurs in 18% of pregnant women.
d) Risk factors: marked obesity, History of gestational diabetes, glycosuria, or
family history of diabetes.
DM Clinical Manifestations
- “Three Ps”
a) Polyuria (excessive urine)
b) Polydipsia (excessive thirst)
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 c) Polyphagia (excessive hunger)
- Fatigue, weakness, vision changes, tingling or numbness in hands or
feet, dry skin, skin lesions or wounds that are slow to heal, recurrent
infections
- Type 1 may have sudden weight loss

Diagnostic Findings
- Fasting blood glucose 126 mg/dL or more (Fasting is defined as no caloric
intake for at least 8 h)
- Random glucose exceeding 200 mg/Dl
• The renal threshold for glucose is 180 to 200 mg/dL.
• Hemoglobin A1c (HbA1c): Average level of blood sugar over the past 2 to 3
months (Red blood cells live for about 3 months, so the test shows the average level
of glucose in your blood for the past 3 months).
DM Treatment
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Goal: Maintain normal blood glucose levels (Hgb A1c <7%)
I. Intensive control
• Insulin injections: three or four per day or continuous subcutaneous
insulin infusion, insulin pump therapy
• frequent blood glucose monitoring
• weekly contacts with diabetic educators
 Diabetic control decreases complications such as retinopathy,
nephropathy, and neuropathy.
II. Dietary Management Goals
• Maintain the pleasure of eating (personal and cultural preferences
• Promote exercise and activity
• Achieve and maintain BMI <25 (A weight loss as small of total weight
may significantly improve blood glucose levels) as 5-10% (BMI = weight (kg) /
height (m) squared).
• Prevent wide fluctuations of blood glucose levels
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 • Decrease serum lipids if elevated (to prevent heart disease)

BMI AND OBESITY

Underweight from 16.0 to 18.5

Normal (healthy weight) from 18.5 to 25
Overweight from 25 to 30
Obese Class I (Moderately obese) from 30 to 35
Obese Class II (Severely obese) from 35 to 40
Obese Class III (Very severely
over 40
obese

Role of the Nurse

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 • Be knowledgeable about dietary management
• Communicate important information to the dietician or other management
specialists
• Reinforce patient understanding
• Support dietary and lifestyle changes
Meal Planning
• Consider food preferences, lifestyle, usual eating times, and cultural
and ethnic background
• Review diet history and need for weight loss, gain, or maintenance
• Caloric requirements and calorie distribution throughout the day;
exchange lists
o Carbohydrates: 50% to 60%; emphasize whole grains (e.g., Oat
‫ الشوفان‬, Barely ‫الشعير‬, Brown rice … etc).
o Fat: 20% to 30%, with >10% from saturated fat and <300 mg
cholesterol;
o Protein: 10% to 20%

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 o Fiber: 25 g daily
• Caloric requirements are based on age, gender, height, and weight.
• To promote a 1- to 2-pound weight loss per week, 500 to 1000 calories are
subtracted from
the daily total.
Nutrition Labels
• The nutrition content of foods listed on the package by the manufacturer.
• How many grams of carbohydrate are in a serving of food? For example, a
patient who takes pre-meal insulin may use the algorithm of 1 unit of insulin for 15 g
of carbohydrate.
• Why carbohydrates? Because it is the main nutrients in food that influence
blood glucose levels.
Glycemic Index
• “How much a given food increases the blood glucose level compared
with an equivalent amount of glucose?”

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 • Combining starchy foods with protein and fat slows absorption and
glycemic response.
• Raw or whole foods tend to have lower responses than cooked,
chopped ‫المقطع‬, or pureed foods ‫المهروس‬.
• Eat whole fruits rather than juices; this decreases glycemic response
because of fiber (slowing absorption).
• Adding food with sugars may produce lower response if eaten with
foods that are more slowly absorbed.
III. Exercise
• Lowers blood sugar
• Aids in weight loss
• Lowers cardiovascular risk

Exercise Precautions
• Exercise elevates blood sugar levels; insulin must be adjusted

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• Physiologically, insulin normally decreases with exercise (but not in
patients treated with insulin); patients on exogenous insulin should eat a 15-g
carbohydrate snack before moderate exercise to prevent hypoglycemia
• (eat a snack at the end of the exercise session and at bedtime )
• Need to monitor blood glucose levels
• Gerontologic considerations (exercise stress test may be warranted
before an exercise program is initiated.)

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IV. Self-Monitoring of Blood Glucose (SMBG)

a) Testing Whole blood vs. plasma glucose (know your device).

o Plasma glucose values are 10% to 15% higher than whole blood
glucose values.
o Testing is recommended whenever hypoglycemia or
hyperglycemia is suspected; with changes in medications, activity, or
diet; with stress or illness.
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b) Testing for Glycated Hemoglobin (HgbA1C, or A1C)
o When blood glucose levels are elevated, glucose molecules
attach to hemoglobin in red blood cells.
o This complex (hemoglobin attached to the glucose) is
permanent and lasts for the life of an individual RBC, approximately
120 days.
o Normal values typically range from 4% to 6% (for patients with DM <
7%).

c) Testing for ketones

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- Ketones: are by-products of fat breakdown, and they
accumulate in the blood and urine.
- Ketones in the urine signal that there is a deficiency of insulin
and control of type 1 diabetes is deteriorating.
- Most commonly, the patient uses a urine dipstick to detect
ketonuria (purple color indicates ketones).
- One of the ketone bodies is called acetone, and this term is
frequently used interchangeably with the term ketones. (Acetone is
responsible for the fruity odor)

Insulin Therapy
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- In type 1 diabetes, exogenous insulin must be administered
- In type 2 diabetes, insulin may be necessary on a long-term basis to
control glucose levels if meal planning and oral agents are ineffective
- Categories of insulin:
1) Rapid acting
2) Short acting (regular) (the only IV insulin)
3) Intermediate acting (NPH)
4) Very long acting (can’t be mixed, this cause precipitation).

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Normal Pancreatic Insulin Release

BR, breakfast; LU, lunch; DI, dinner; SN, snack;

One Injection Per Day

NPH, neutral protamine Hagedorn; regular; ↑,

insulin injections.

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Two Injections Per Day—Mixed

Before breakfast and dinner:

• NPH or
• NPH with rapid-acting insulin or
• Premixed (rapid-acting insulin) insulin

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Three or Four Injections Per Day

Rapid-acting insulin before each meal with:

• NPH at dinner or
• NPH at bed-time or
• Glargine 1 or 2 times/d

Glargine, very long acting insulin

Insulin Pump

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Uses ONLY rapid-acting insulin infused at continuous, low rate called basal rate (commonly
0.5–1.5 units/h) and pre-meal bolus doses activated by pump wearer

Complications of insulin therapy

1) Local Allergic Reactions. May appear at the injection site 1 to 2 hours
after administration of insulin (usually resolve in a few hours).
2) Systemic Allergic Reactions (rare).
3) Insulin Lipodystrophy, either

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- lipoatrophy, loss of subcutaneous fat or,
- lipohypertrophy, development of fibrofatty masses at the injection site,
caused by repeated use of an injection site (rotation of injection sites is so
important).
4) Morning hyperglycemia.

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Educating Patients in Insulin Self-Management
- Use and action of insulin
- Symptoms of hypoglycemia and hyperglycemia
- Required actions
- Blood glucose monitoring
- Self-injection of insulin
- Insulin pump use
Question: What category of insulin is rapid acting?
a) Humalog
b) Humalog R
c) Humulin N
d) Glargine (Lantus)

 Aspart is a rapid-acting insulin, Humalog R is a short-acting insulin,

Humulin N is an intermediate-acting insulin, and Glargine (Lantus) is a very
long-acting insulin.
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Oral Antidiabetic Agents
- Used for patients with type 2 diabetes who require more than diet and
exercise alone
- Combinations of oral drugs may be used
- Major side effect: hypoglycemia
- Nursing interventions: monitor blood glucose for hypoglycemia and other
potential side effects
- Patient education
Sites of Action of Oral Antidiabetic Agents
- Biguanides: Metformine (Glucophage): Reduce the production of
glucose by the liver, Intestinal glucose absorption ↓, Insulin action ↑
- Sulfonylureas: glimepiride (Amaryle): Stimulate the pancreas to
produce more insulin, Before meal 30m, don’t take at bed time (hypoglycemia

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- Thiazolidinediones: increase insulin sensitivity by the body cells and
reduce the production of Glucose by the liver

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 Alpha-glucosidases Acarbose (Glucobay ) slow the absorption of
carbohadrate ingested. Bloating and flatulence (gaz)
Dipeptidyl- peptidase-4 inhibitors: intensify the effect of intestinal
hormones (incretines) involved in the control of bloodsugar

Nursing Management
- Managing Glucose Control in the Hospital Setting
o Hyperglycemia can prolong lengths of stay and increase
infection rates and mortality.
o Blood glucose targets are 140 to 180 mg/dL.
o Insulin (subcutaneous or IV) is preferred to oral antidiabetic
agents to manage hyperglycemia.

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 o Appropriate timing of blood glucose checks, meal consumption,
and insulin dose.
- Providing Patient Education
o Healthy eating,
o Being active,
o Monitoring,
o Taking medication,
o Problem solving,
o Healthy coping, and
o Reducing risks.
- Avoid long-term diabetic complications
o foot care,
o eye care,
o skin care and oral hygiene,
o Risk factor management (e.g., blood pressure control and blood
glucose normalization (cholesterol/lipid control)
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 - Educating Patients to Self-Administer Insulin
- Insulin are self-administered into the subcutaneous tissue with
the use of special insulin syringes.
- Insulin should be refrigerated when not in use.
- Insulin should not be allowed to freeze.
- The insulin vial in use should be kept at room temperature (to
reduce local irritation).
- If a frosted, adherent coating is present on the vial, some of the
insulin is bound, inactive, and should not be used.
Types of Insulin syringes
- 1-mL syringe, 100-unit capacity
- 0.5-mL syringe, 50-unit capacity
- 0.3-mL syringe, 30-unit capacity

- Systematic rotation of injection sites within an anatomic area is

recommended to prevent localized changes in fatty tissue (lipodystrophy).
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 - The use of alcohol to cleanse the skin is not necessary.
- The mnemonic “tie” helps the patient remember the order of activities
(“t” = test [blood glucose], “i” = insulin injection, “e” = eat)

Acute Complications of Diabetes

1) Hypoglycemia
2) DKA
3) Hyperglycemic hyperosmolar syndrome (HHS)

Hypoglycemia
- Abnormally low blood glucose level (below 50–60 mg/dL);
- Causes:

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 o too much insulin or oral hypoglycemic agents, excessive
physical activity, and not enough food
- Symptoms:
o Adrenergic symptoms: sweating, tremors, tachycardia,
palpitations, nervousness, hunger
o Central nervous system symptoms: inability to concentrate,
headache, confusion, memory lapses, slurred speech, drowsiness,
irrational or combative behavior.
o Severe hypoglycemia: disorientation, seizures, loss of
consciousness, death
- Management
- Give 15 g of fast-acting, concentrated carbohydrate
- Three or four glucose tablets
- 4 to 6 oz of juice or regular soda (not diet soda). (1 oz = 30 ml)
(1 cup = 250 ml).

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 - Retest blood glucose in 15 minutes; retreat if < 70 mg/dL or if
symptoms persist more than 10 to 15 minutes and testing is not
possible
- Provide a snack with protein and carbohydrate unless the
patient plans to eat a meal within 30 to 60 minutes
- Emergency Measures
- If the patient cannot swallow or is unconscious:
o Subcutaneous or intramuscular glucagon (1 mg). its
onset of action is 8 to 10 minutes, and lasts 12 to 27 minutes)
o 25 to 50 mL of 50% dextrose solution IV
o It is important that patients with diabetes, especially
those receiving insulin, learn to carry some form of simple
sugar with them at all times
Diabetic Ketoacidosis (DKA)

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 - Absence or inadequate amount of insulin resulting in abnormal
metabolism of carbohydrate, protein, and fat
- Clinical features
- Hyperglycemia
- Dehydration
- Acidosis
- Three main causes of DKA are
1) Decreased or missed dose of insulin,
2) Illness or infection, and
3) Undiagnosed and untreated diabetes (DKA may be the initial
manifestation of type 1 diabetes).

DKA Pathophysiology
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“Sick day rules”: refer to Chart 51-9

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Assessment of DKA
- Assess Blood glucose levels >300 to 1,000
- Monitor signs and symptoms:
o Polyuria, polydipsia (increased thirst), and marked fatigue.
o The ketosis and acidosis of DKA lead to gastrointestinal
symptoms such as anorexia, nausea, vomiting, and abdominal pain
- Ketoacidosis is reflected in low serum bicarbonate, low pH; low PCO2
reflects respiratory compensation (Kussmaul’s respirations; deep, labored
breathing)
- Ketone bodies in blood and urine. The patient may have acetone
breath (a fruity odor)
- Electrolytes vary according to degree of dehydration; increase in
creatinine, Hct, BUN
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Treatment of DKA
- Rehydration with IV fluid
- IV continuous infusion of regular insulin
- Reverse acidosis and restore electrolyte balance
- Note: rehydration leads to increased plasma volume and decreased K;
insulin enhances the movement of K+ from extracellular fluid into the cells.
- Because extracellular potassium levels decrease during DKA treatment,
potassium must be infused even if the plasma potassium level is normal.
- Monitor blood glucose, renal function and urinary output, ECG,
electrolyte levels, VS, lung assessments for signs of fluid overload
- The acidosis is reversed with insulin (inhibits fat breakdown and ending
ketone production and acid buildup.

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Hyperglycemic Hyperosmolar Syndrome
- caused by a lack of sufficient insulin; ketosis is minimal or absent
- Manifestations include hypotension, profound dehydration,
tachycardia, and variable neurologic signs caused by cerebral dehydration
- High mortality rate
- Hyperglycemia causes osmotic diuresis, loss of water and electrolytes,
hypernatremia, and increased osmolality
- Occurs most often in older people (50 to 70 years of age) who have
type 2 diabetes.
- HHS often can be traced to an infection or an acute illness (↑ insulin
demand).

What distinguishes HHS from DKA?

- Ketosis and acidosis generally do not occur in HHS.
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- In DKA, no insulin is present, and this promotes the breakdown of
stored glucose, protein, and fat, which leads to the production of ketone
bodies and ketoacidosis.
- In HHS, the insulin level is too low to prevent hyperglycemia (and
subsequent osmotic diuresis), but it is high enough to prevent fat
breakdown.

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 - Treatment of HHS
- The overall approach to the treatment of HHS is similar to that of DKA:
- Fluid replacement, correction of electrolyte imbalances, and insulin
administration.

- Prevention
- BGSM
- Diagnosis and management of diabetes
- Assess and promote self-care management skills

Long-Term Complications of Diabetes

- Macrovascular: accelerated atherosclerotic changes, coronary artery
disease, cerebrovascular disease, and peripheral vascular disease

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- Microvascular: diabetic retinopathy (refer to Figure 51-8), and
nephropathy
- Neuropathic: peripheral neuropathy, autonomic neuropathies,
hypoglycemic unawareness, neuropathy, sexual dysfunction

Neuropathic Ulcers

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Continuous glucose monitoring system (CGMS)
- A device worn for 72 hours that continuously monitors blood glucose
levels;
- the data are downloaded and analyzed for blood glucose patterns for
that time period;
- used in diagnosis and treatment

:CGMS ‫نظام مراقبة الجلوكوز بشكل مستمر‬ •

.‫ ساعة لمراقبة مستويات السكر في الدم‬72 ‫جهاز يرتديه مريض السكر لمدة‬ •
‫ يستخدم في‬.‫يتم تحميل البيانات وتحليلها لنماط السكر في الدم لتلك الفترة الزمنية‬
‫التشخيص والعلجا‬
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Continuous subcutaneous insulin infusion
pump
- A small device that delivers insulin on a 24-hours basis as basal insulin;
programmed by the patient to deliver a bolus dose before eating a meal
‫ يبرمج هذا الجهاز من قبل المريض‬.‫ ساعة‬24 ‫جهاز صغير لعطاء النسولين على مدار‬
‫لعطاء جرعة انسولين قبل تناول الوجبة‬

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