DIABETES

DM Type 1 and DM Type 2

0 - 7.5
7.6 - 8.7
8.8 - 10.3
> 10.4

Diabetes affects 25.8 million people; accounting for 8.3% of

the U.S. population
http://diabetes.niddk.nih.gov/dm/pubs/statistics/#fast

The Yearly Toll of Diabetes in New York City

http://www.cdc.gov/obesity/data/adul
t.html
http://www.nyc.gov/html/doh/html/pr2007/pr060-07.shtml

Risk for Diabetes Quiz: Answer yes or no

1.
2.
3.
4.
5.
6.
7.
8.

I have a parent, brother, or sister with diabetes.

My family background is African-American, American
Indian, Asian American, Hispanic or Pacific Islander.
I have had gestational diabetes or gave birth to at least
one baby weighing nine pounds or more.
I have pre-diabetes (FBS of 100-126).
I am overweight.
I am fairly inactive & exercise < 3 times per week.
I have high BP.
My cholesterol levels are abnormal. My LDL is > 100;
my HDL is < 35; my triglyceride level is 250 or >.

Answers to Diabetes Quiz

If you answered Yes to one or more questions,
you are at risk for type 2 diabetes.
Your chance of getting diabetes are higher if you
answered Yes to three or more.
Check your levels are regular intervals and make
changes in your eating and exercise habits.

 Is an exocrine gland
Releases digestive
enzymes

Is an endocrine gland
Beta calls in the Islets
of Langerhans
Produce & secrete
insulin in response to
rising blood sugars

Pancreas

HOW GLUCOSE GETS

INTO THE BLOOD
STREAM:
- Intestines: absorption
of simple sugars
- Liver: Glycogen -->
glucose
(glycogenolysis)
- Protein catabolism
(glyconeogenesis)

WHAT IS GLUCOSE
USED FOR?
- In tissues: oxidation
(CO2 + H2O + E)
- In liver glycogen
formed
- Converted to fat
- In muscles (stored as
glycogen)
- Excreted in urine
(BS level is > 200)

What does Insulin do?

Transports & metabolizes glucose for E
Stimulates the storage of glucose in the liver
--> glycogen (Glycogenesis)
Enhances the storage of fat in adipose tissue
Transports amino acids & glucose into the cells
Inhibits the breakdown of stored glucose,
protein, & fat

Fasting
Pancreas releases insulin
+
Pancreas releases Glucagon
(glycogenolysis)
=
Constant level of BS
8-12 hrs w/o food Glyconeogenesis

TYPE 1 Diabetes Mellitus (DM)

Pathophysiology:
Destruction of beta cell
Glucose not stored as glycogen
Glycogenolysis & gluconeogenesis occur
unrestrained
Fat breakdown occurs

ALL --> HYPERGLYCEMIA

TYPE 2 Diabetes Mellitus (DM)

Etiology:
Insulin resistance
AND/OR
Decreased production of Insulin

ALL --> HYPERGLYCEMIA

DM Diagnostic Tests:
Fasting glucose level of 126 mg/dL or >
Random glucose level of 200 mg/dL or > on
more than one occasion
Hemoglobin A1C > 6.5 or 7

Nursing Interventions for

Hyperglycemia
1.

Check blood sugar

Type 1 DM: 2-4/day

Type 2 DM: 2-3/wk

One 2hr postprandial

Type 1 or 2
hospitalized:
Fractionals
AC & bedtime

Fractionals or
Sliding scale:
BS
Insulin dose
150-199
2 units
200- 249
4 units
250-299
6 units
300-349
8 units
350-399
10 units
> 400
Call MD

Nursing Interventions for

Hyperglycemia
2. Fluids
3. Airway
4. Patient teaching
5. Diet
- CHO 50%, Protein 25%,
Fat 25%, Fiber
*WEIGHT CONTROL*
6. Activity & exercise
7. Oral meds (Type 2 only)
8. Decrease stress

Oral meds for Type 2 DM:

1. For Insulin Resistance
Antihyperglycemic agents
- Glucophage, Precose, Glycet,
Actos, Avandia
2. For Decrease Insulin
production:
Hypoglycemic agents
- Diabinase, Glucotrol,
Micronase, Prandin

IMPAIRED INSULIN PRODUCTION:

ORAL HYPOGLYCEMICS
CATAGORY

DRUG

Sulfonylureas Prototype:
glipizide
(Glucotrol)

ACTION

ADE

Insulin
production

Hypoglycemia
Common: N,
abd fullness

Insulin
production

Hypoglycemia

Glyburide
(Miconase,
DiaBeta)
Megitinide

Repaglinide
(Prandin)
Nateglinide
(Starlix)

DECREASE INSULIN RESISTANCE:

ANTIHYPERGLYCEMICS
CATEGORY

DRUG

ACTION

ADE

Thiazolidinediones

Pioglitazone
(Actos))

Insulin
resistance

incidence of
angina, MI

Biguanide

Prototype:
Insulin
metformin
resistance,
(Glucophage) hepatic
glucose
prod

Black box:
lactic
acidosis
Common:
N, V, abd
discomfort

Alpha-Glucosidase
Inhibitors

Miglitol
(Glyset)
Acarbose
(Precose)

Abd
discomfort, D,
flatulence

Delays GI
absorption
of glucose

Things to know about Insulin

TIME
Rapid acting

AGENT
Humalog
(Lispro)

ONSET PEAK
10-15min 1 h

DURAT INDICA.
3h
-rapid
reduction
of BS

Regular
R
- NPH
Humulin N
- Lente Humulin
L
Ultralente
UL
glargine (Lantus)

1/2-1 h

2-3 h

4-6 h

3-4 h

4-12 h

16-20 h

6-8 h

12-16 h

20-30 h

1h

No
Peak

24 h

(clear)
Short acting
(clear)
Intermediate
acting
(cloudy)
Long acting
(cloudy)
Long acting
(clear)

Give 20-30
min ac
Give pc

Control s
FPG
Do NOT
mix with
other
insulins

Things to know about Insulin

In General:
70/30 Insulin: 70% NPH & 30% Regular
Rapid & short acting Insulin cover meals
immediately AFTER the injection
Intermediate acting Insulin is expected to cover
subsequent meals
Long acting Insulin provides a relatively
constant level of Insulin and act as a basal
Insulin

Things to know about Insulin

Only Regular Insulin
in given IV
Rotates site
Mixing types:
clear to cloudy

Insulin Regimes
1 injection/day
CONVENTIONAL
2 injections/day

INTENSIVE
3-4 injections/day

Things to know about Insulin

Insulin Pens

Insulin Pumps

Hypoglycemia: Assessment
Too little food/ To much Insulin or DM meds/
Extra activity
1. Blood sugar < 60
2. Nervousness,
trembling
3. Increase SNS
4. Moist, clammy skin
5. Dizziness, anxious,
hunger

6. Impaired vision
7. Weakness, fatigue
8. Confusion, irritable,
restless
9. Convulsions w/
BS < 40
10. Coma --> death

Hypoglycemia: Nursing Interventions

Give sugar
Glucagon IV
Check VS
Monitor BS
On going assessment
Comatose - maintain
airway
Patient education

Old Saying:
Cold and clammy means you
need some candy
Hot and dry your sugar is to
high!

Classifying Hypoglycemia
MILD

MODERATE

SEVERE

Conscious

Conscious

Unconscious

Hunger
Diaphoresis
Tremor
Anxiety or drowsiness
Weakness

Headache
Behavior change
Blurred, impaired or
double vision
Irritation or confusion,
difficulty talking

Unresponsive unable
to take oral feeding
Seizure activity

Food with 15 grams of carbohydrates:

3 to 4 chewable glucose tablets
1 tablespoon of jam
I tube of glucose gel
4 to 6 ounces of fruit juice
4 to 6 ounces of regular soft drink
3 packets of sugar or 1 tablespoon of sugar
1 tablespoon of honey
5 to 7 hard candies

Diabetic Testing
Self Monitoring of BS
Glycosylated
Hemoglobin A1C
Hgb A1C

Urine
Ketones
For Type 1 DM esp for
BS>200

Correlating A1C with

average BS
7

154

183

212

10

240

11

269

12

289

DM: Complication
1. Insulin Therapy
2. Diabetic Ketoacidosis
Type 1 DM
Clinical Picture:
Hyperglycemia
FVD
Acidosis

Nursing Assessment:
BS of 300-800
Resp: rapid & deep
Acidosis
Ketones
FVD & electrolyte loss
Medical Management DKA:
Insulin
Hydration
NS or 0.45NS
Electrolyte loss K
Acidosis

Sick Day Rules for Type 1 and 2:

Take Insulin/oral meds as usual
Test BS q 3-4 hrs
Type 1 BS > 200 test for ketones

Report BS > 300

Small, freq meals
V or D: c cola, juice, or broth q hr
Report N/V/D to MD

DM: Complication
3. Hyperglycemic Hyperosmolar Nonketotic
Syndrome (HHNS):
Clinical Picture:
- Hyperglycemia
- FVD
- Tachycardia
- Alteration in
Sensorium

Nursing assessment:
- Type 2 DM
- BS > 1,000
- RR: WNL
- pH: WNL
- No ketones
Prevention: Sick Day
Rules

Parameter

DKA

HHNK

Diabetes

Type 1

Type 2

Serum glucose

300-800

Often > 1,000

Arterial pH

Acidic

Normal

Serum ketones

Positive

Negative

Urine ketones

Positive

Negative

Onset

Quick

slowly

Cause:

Lack of Insulin
breakdown of fats

Lack of enough
Insulin, but enough to
prevent the
breakdown of fats

Clinical Assessment

Dry skin & mucous

membranes, < skin
turgor, tachycardia,
hypotension, altered
LOC

Dry skin & mucous

membranes, < skin
turgor, tachycardia,
hypotension, altered
LOC

Kussmauls Resp

Regular & shallow

5-30%

Near 50%

Mortality

DM: Complication
4. MACROVASCULAR
CAD
CVD
PVD
5. MICROVASCULAR
Retinopathy
Nephropathy
6. NEUORPATHIES
Peripheral
(sensorimotor)
Autonomic:
CV GI
Urinary
Adrenal

DIABETES
INSIPIDUS
A Pituitary disorder
Leads to polyuria and polydipsia
Treatment:

Replace fluids,
I&O
Diet: Hi Na & hi K
Aqueous vasopressin (Pitressin) or
Desmorpressin (Stimate)

Metabolic Syndrome or
Syndrome X
Cluster of risk factors:

High Triglycerides: > 150

Low HDL: < 40
High BP: > 130/85
Insulin-resistance: BS 110-125
Waist:
Females: > 35 inches
Males: > 40 inches