Nur 105

Adult Health I

DIABETES MELLITUS
Jackie C. Williams, RN-C, MSN
Shelton State Community College
 DEFINITION
DIABETES 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 Mellitus
Pathophysiology
 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 Mellitus
Types
 Type 1 - IDDM  Type 2 - NIDDM
 little to no insulin  some insulin
produced produced
 20-30% hereditary  90% hereditary
 Other types include Secondary
 Ketoacidosis Diabetes :
 Genetic defect beta cell
or insulin
 Disease of exocrine
 Gestational pancreas
 Drug or chemical induced
 overweight; risk for  Infections-pancreatitits
 Others-steroids,
Type 2
 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 Mellitus
Clinical Manifestation
 Hyperglycemia  Hypoglycemia
 Three P’s -  Weak, diaphoretic,
 Polyuria sweat, pallor,
tremors, nervous,
 Polyphagia hungry, diplopia,
confusion, aphasia,
 Polydispsia vertigo, convulsions
 Treatment - OJ with
sugar, or IV glucose

 Gradual Onset  Sudden onset

 Hyperglycemia - Clinical
Manifestations
 Three P’s –  Fever
polyuria,  Hypokalemia
polydypsia,  Hyponatremia
polyphagia  Seizure
 Glycosuria  Coma
 Dehydration
 Hypotension
Life Threatening!!!
 Mental Changes
 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 Hypoglcemias
Key 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 Mellitus
Diet
 American Diabetic
Association
 Food groups/
exchanges
 Carbohydrates -
60%
 Fats - 30%
 Protein - 12-20%
Diabetes - Monitoring Glucose
Levels
 Urine - Ketones

 FSBS

 Wear ID Bracelet
Diabetes - Treatment
Exercise
 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
 Diabetic Neuropathy
 Proper skin and
foot care  Diabetic Retinopathy
 Proper Eye Exam
 Diabetic
Nephropathy
 Proper diet and
fluids  Diabetic
gastroparesis
 Diabetes Mellitus
Complications
 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 – Ketoacidosis
Treatment
 Patent airway  Administration of
 Suctioning Na Bicarb
 Cardiac monitoring  Foley – monitor
 Vital Signs urinary output
 Central venous
 I&O
pressure  Frequent
 Blood work – ABG, Repositioning
BS, chemistry
panel
 Complication – HHNC
Hyperosmolar Hyperglycemic
Non-Ketotic Coma
 Fluid moves from  Signs and Symptoms
inside to outside cell  Hypotension
vausing diuresis and  Mental changes
loss of Na+ and K+  Dehydration
 Hypokalemia
 Treatment - Give
 Hyponatremia
insulin and correct fluid
and electrolytes
imbalance
 Life Threatening!!!
 Chronic Complications of
Diabetes
 Cardiovascular disease
 Cerebrovascular disease
 Retinopathy (vision) problems
 Diabetic neuropathy
 Diabetic nephropathy
 Male erectile dysfunction
 Diabetes Mellitus
Nursing 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:
Monitoring
Fluid therapy: to
rehydrate the client and
restore normal blood
glucose levels within 36
to 72 hr
Continuing therapy with
IV regular insulin at 10
units/hr often needed to
Health Teaching
 Assessing learning needs
 Assessing physical, cognitive, and
emotional limitations
 Explaining survival skills
 Counseling
 Psychosocial preparation
 Home care management
 Health care resources
 Diabetes Mellitus
Summary
 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.