DIABETIC PRESENTATION

 DEPARTMENT CLINICAL NURSING
 MEDICAL NURSING
 PRESENTATION:DIABETES MELLITUS
 PRESENTER:SONGOMA JOHN
 Reg-2009-04-01476
 SUPERVISOR: Dr LESHABARI
Friday, March 18, 2022 1
Songoma JM .MUHAS

 Diabetes mellitus is a group of metabolic
diseases in which defects in insulin
secretion or action result in high blood
sugar level (hyperglycemia).
The incidence of diabetes mellitus varies
by race and ethnicity. In the United
States, Hispanic, black, Native American,
Alaska Native, and Asian American
populations have a higher rate of diabetes
than non-Hispanic white ethnic groups.
Songoma JM .MUHAS

 Diabetes is a serious disease that can
cause complications such as blindness,
kidney failure, heart attacks, and strokes.
 It is a leading cause of lower limb
amputation.
 With good education and self-care,
patients with diabetes can prevent or
delay these complications and lead full,
productive lives
 . A major role of the nurse is helping the
patient learn self care
Songoma JM .MUHAS

Diabetes results from faulty production of
insulin by the beta cells in the pancreas,
or from inability of the body’s cells to use
insulin. When glucose is unable to enter
body cells, it stays in the bloodstream;
hyperglycemia results, and the cells are
denied their energy source.
Abnormal glucagon secretion may also
play a role in type 2 diabetes.
Songoma JM .MUHAS

Type 1 Diabetes Mellitus
 Type 1 diabetes (formerly called juvenile
diabetes mellitus, insulin-dependent diabetes
mellitus, or IDDM) is the type of diabetes which
caused by destruction of the beta cells in the
islets of Langerhans of the pancreas hence
unable to produce insulin.
 Insulin must then be injected for the body to
use food for energy.
Only 5% to 10% of people with diabetes have
type 1 diabetes
Songoma JM .MUHAS

1. . Genetic predisposition for increased
susceptibility.
2. Environmental triggers stimulate an
autoimmune response
3. Viral infections (mumps, rubella
coxsackievirus B4)
4. Chemical toxins
Songoma JM .MUHAS

 LADA- This is a new type of type 1 diabetes that
has recently been identified.
 Some patients who were initially diagnosed with
type 2 diabetes were later found to have islet cell
and insulin antibodies (which are usually associated
with type 1), and their blood glucose levels were
not controlled with oral medications.
 However, beta cell destruction tended to occur
more slowly than with type 1 diabetes.
 Patients with LADA can be distinguished as either
thin or obese because the disorder has slightly
different characteristics depending on the patient’s
body fat.
Songoma JM .MUHAS

(formerly called adult-onset diabetes mellitus,
non–insuline -dépendent diabetes mellitus, or
NIDDM).
 This is a type of diabetes mellitus where by
tissues are resistant to insulin.
 . Insulin is still made by the pancreas, but in
inadequate amounts.
 Sometimes the amount of insulin is normal or
even high, but because the tissues are resistant
to it, hyperglycemia results.
Songoma JM .MUHAS

 Gestational diabetes mellitus (GDM) –This is a
diabetics which develop during pregnancy,
especially in women with risk factors for type 2
diabetes.
 The extra metabolic demands of pregnancy trigger
the onset of diabetes.
 Blood glucose usually returns to normal after
delivery, but the mother has an increased risk for
type 2 diabetes in the future.
 If the mother with GDM is overweight, she should
be counseled that weight loss and exercise will
decrease her risk of later developing diabetes.
 Mothers with GDM require specialized care and
should be referred to an expert in this area
Songoma JM .MUHAS

 Prediabetes refers to blood glucose levels that
are above normal but do not meet the criteria
for diagnosing diabetes.
 Prediabetes usually occurs prior to the onset of
type 2 diabetes.
 It is diagnosed by evaluating glucose tolerance
or fast-ing glucose level.
 Individuals with prediabetes may be able to
prevent the onset of diabetes with weight loss
and exercise.
Songoma JM .MUHAS

 Secondary diabetes may develop as a result of
another chronic illness that damages the islet cells,
such as pancreatitis or cystic fibrosis.
 Prolonged use of some drugs, such as steroid
hormones, phenytoin (Dilantin), thiazide diuretics,
and thyroid hormone, may also impair insulin action
and raise blood glucose.
 Maturity-onset diabetes of the young (MODY) is an
inherited defect in insulin secretion that usually
occurs in individuals under the age of 25.
 Less common causes include pancreatic trauma
and other endocrine
Songoma JM .MUHAS

 Polyuria (hyperglycemia acts as osmotic
diuretic)
 Glycosuria (renal threshold for glucose: 180
mg/dL)
 Polydipsia (thirst from dehydration from
polyuria)
 Polyphagia (hunger and eats more since cell
cannot utilize glucose)
 Weight loss (body breaking down fat and protein
to restore energy source
 Malaise and fatigue (from decrease in energy)
 Blurred vision (swelling of lenses from osmotic
effects)
 Headache
 Abdominal pain
Songoma JM .MUHAS

 FASTING PLASMA GLUCOSE.
 Diagnosis of diabetes mellitus is based on plasma
glucose levels measured by a laboratory.
 A normal plasma glucose level is less than 100
mg/dL, although different laboratories may have
slightly different normal values.
 When the fasting plasma glucose (drawn after at
least 8 hours without eating) is 126 mg/dL, diabetes
is diagnosed.
 A second test may be required if the first test is not
clearly diagnostic.
 If the fasting plasma glucose is between 100 and
125 mg/dL, the patient has impaired fasting glucose
(IFG)
Songoma JM .MUHAS

 CASUAL PLASMA GLUCOSE.
 Sometimes it is not feasible to check a
fasting plasma glucose.
 A casual plasma glucose (CPG) is checked
without regard to the last meal.
 Diabetes is diagnosed if the CPG is 200
mg/dL, with symptoms of diabetes.
Songoma JM .MUHAS

 ORAL GLUCOSE TOLERANCE TEST.
 Another test to diagnose diabetes is the
oral glucose tolerance test (OGTT).
 An OGTT measures blood glucose at
intervals after the patient drinks a
concentrated carbohydrate drink.
 Diabetes is diagnosed when the blood
glucose level is 200 mg/Dl after 2 hours.
 A result between 140 and 199 mg/dL at 2
hours diagnoses impaired glucose
tolerance (IGT).
Songoma JM .MUHAS

• GLYCOHEMOGLOBIN.
• The glycohemoglobin test (also called
glycosylated hemoglobin, or HbA1c) is used to
gather baseline data and to monitor progress of
diabetes control (not to diagnose diabetes).
• Glucose in the blood attaches to hemoglobin in
the red blood cells.
• When the glucose that is attached to the
hemoglobin is measured, it reflects the average
blood glucose level for the previous 2 to 3
months.
• A normal HbA1c is 4% to 6%
• . This is a helpful measurement when blood
glucose levels fluctuate and a single
Songoma JM .MUHAS

 ADDITIONAL TESTS.
 Because diabetes affects so many body
systems, additional tests recommended
for baseline data include a lipid profile,
serum creatinine and urine microalbumin
levels to monitor kidney function,
urinalysis , and electrocardiogram
Songoma JM .MUHAS

 The only cure for diabetes is a pancreas (or
islet cell) transplant.
 However, diabetes can be controlled.
 Treatment begins with diet and exercise.
 Insulin is added in patients with type 1
diabetes and insulin or oral hypoglycemic
medication as needed in those with type 2
diabetes.
 Blood glucose monitoring and education are
also important to good diabetes control.
 To monitor the effectiveness of treatment,
patients should have regular health care
follow-up visits.
Songoma JM .MUHAS

 INJECTED INSULIN.
 The individual with type 1 diabetes has no
endogenous insulin and therefore must
administer insulin daily.
 Insulin is generally given subcutaneously,
although fast-acting insulin may be ordered via
the intramuscular or intravenous route in urgent
situations, or sometimes inhaled.
 There are several types of insulin and schedules
by which it may be given.
 In general, the more frequent the injections,
the better the glucose control.
Songoma JM .MUHAS

 Insulin injections should be given in a
different subcutaneous site each time to
avoid injury to the tissues.
 Because each area absorbs insulin at a
slightly different rate, it is advisable to use
one area for a week, then move on to the
next Within that area, each injection should
be spaced at least 1 inch from the previous
injection.
 Most experts recommend using primarily the
torso (abdomen and buttocks) to provide
more uniform absorption
Songoma JM .MUHAS

• INHALED INSULIN
• . A new short-acting human insulin that
can be inhaled, Exubera. Exubera is a dry
powder insulin that can actually enter the
circulation via the lungs faster than a
subcutaneous injection.
• It can reduce lung function slightly, so
patients must have pulmonary function
tests before using it.
• It cannot be used by patients who smoke
or who have quit smoking within the last
6 months.
Songoma JM .MUHAS

• . Two problems that can occur with glucose control
are the Somogyi effect and the dawn phenomenon.
• The Somogyi effect may be at fault when the
patient’s blood glucose seems to be rising in spite
of increasing insulin doses.
• If insulin levels are too high, the blood glucose may
drop too low, stimulating release of counter
regulatory hormones (epinephrine, glucagon,
corticosteroids, growth hormone) that then elevate
the blood glucose.
Songoma JM .MUHAS

 The low glucose levels often occur during
the night, and the patient may report night
sweats or morning headaches.
 The high morning glucose is then interpreted
as hyperglycemia, and the insulin dose may
be further increased, compounding the
problem.
 The dawn phenomenon is thought to occur
because of the natural release of growth
hormone and cortisol during the early
morning hours.
 This causes hyperglycemia on arising
Songoma JM .MUHAS

 The patient with type 2 diabetes may be able
to control blood glucose levels with medical
nutrition therapy and exercise alone.
 Oral hypoglycemic medication or insulin may
also be prescribed.
 Oral hypoglycemics are not insulin pills.
 Remember that if insulin is ingested, it is
digested, because it is a protein.
 Because most oral hypoglycemic agents
depend on at least a partially functioning
pancreas, most are not useful for patients
with type 1 diabetes
Songoma JM .MUHAS

 Complication of diabetics can be :-
1. Acute complication
a) Hyperglycemia
b) Hypoglycemia
c) Diabetes Ketoacidosis
d) Hyperosmolar , hyperglycemic,
nonketotic (HHNK)
2)Chronic complication or longer term
complication
Songoma JM .MUHAS

 When calories eaten exceed insulin
available or glucose used, high blood
glucose (hyperglycemia) occurs.
 CAUSES
 Overeating
 Stress
 Illness
 Too little insulin or medication
Songoma JM .MUHAS

SYMPTOMS
 Polyuria
 Polydipsia
 Polyphagia
 Blurred vision
 Headache
 Lethargy (Weakness characterized by a lack
of vitality or energy)
 Abdominal pain
 Ketonuria (if type I)
 Coma
Songoma JM .MUHAS

 TREATMENT
 Confirm hyperglycemia with glucose meter;
if greater than 300 mg/dL, check urine for
ketones and increase fluid intake.
 Assess cause of hyperglycemia, teach
prevention.
 Return to prescribed treatment plan if
applicable.
 Call physician for medication adjustment if
indicatedor if blood glucose is 200 mg/dL for
2 days.
Call physician if patient is ill or vomiting
Songoma JM .MUHAS

 Hypoglycemia is usually defined as a blood
glucose level below 50 mg/dL, although
patients may feel symptoms at higher or
lower levels. This is sometimes referred to as
an insulin reaction . It occurs when there is
not enough glucose available in relation to
circulating insulin.
CAUSES
 Under eating
 skipping a meal
 Too much insulin or medication
 Exercise
Songoma JM .MUHAS

SYMPTOMS
 Hunger
 Sweating
 Tremor
 Blurred vision
 Headache
 Irritability
 Confusion
 Seizures
 Coma
Songoma JM .MUHAS

TREATMENT
 Confirm hypoglycemia with glucose meter (if
patient is not acutely ill).
 Administer 15 g fast-acting carbohydrate.
 Recheck glucose in 15 minutes; if still low,
readminister carbohydrate.
 Continue cycle of checking glucose and
administering fast sugar until hypoglycemia
subsides; if symptoms worsen, call physician
or emergency help
 .Glucagon subcutaneously or dextrose 50% IV
may beadministered if ordered.
 Assess cause of hypoglycemia, teach
prevention.
Songoma JM .MUHAS

 Results from breakdown of fat and
overproduction of ketones by the liver and
loss of bicarbonate
 Occurs when Diabetes Type 1 is
undiagnosed or known diabetic has
increased energy needs, when under
physical or emotional stress or fails to take
insulin
 Mortality as high as 14%
Pathophysiology
 Hypersomolarity (hyperglycemia,
dehydration)
 Metabolic acidosis (accumulation of
ketones)
 Fluid and electrolyte imbalance (from
osmotic diuresis)
Songoma JM .MUHAS

Diagnostic tests
 Blood glucose greater than 250 mg/dL
 Blood pH less than 7.3
 Blood bicarbonate less than 15 mEq/L
 Ketones present in blood
 Ketones and glucose present in urine
 Electrolyte abnormalities (Na, K, Cl)
 serum osmolality < 350 mosm/kg (normal
280-300)
Songoma JM .MUHAS

Signs and symptoms
 Kussmals respirations
 Blow off carbon dioxide to reverse
acidosis
 Fruity breath
 Nausea/ abdominal pain
 Dehydration
 Lethargy
 Coma
 Polydipsia, polyuria, polyphagia
Songoma JM .MUHAS

Treatment
 Requires immediate medical attention
and usually admission to hospital
 Frequent measurement of blood glucose
and treat according to glucose levels with
regular insulin (mild ketosis,
subcutaneous route; severe ketosis with
intravenous insulin administration)
 Restore fluid balance: initially 0.9%
saline at 500 – 1000 mL/hr.; regulate
fluids according to client status; when
blood glucose is 250 mg/dL add dextrose
to intravenous solutions
Songoma JM .MUHAS

• Correct electrolyte imbalance: client often is
initially hyperkalemic
 As patient is rehydrated and
potassium in pushed back into the
cell they become hypokalemic
 Monitor K levels
 Monitor cardiac rhythm since
hypokalemia puts client at risk for
dysrrhythmias
• Treat underlying condition precipitating DKA
• Acidosis is corrected with fluid and insulin
therapy and rarely needs bicarbonate
Songoma JM .MUHAS

 PATHOPHYSIOLOGY.
 Hyperosmolar, hyperglycemic, nonketotic
(HHNK) syndrome occurs primarily in type
2 diabetes, when blood glucose levels are
high as a result of stress or illness.
 Because the person with type 2 diabetes
has some insulin production, cells do not
starve and DK usually does not occur
Songoma JM .MUHAS

 . HHNK occurs more often in the elderly.
 As the blood glucose rises
(hyperglycemic), polyuria causes profound
dehydration, producing the hyperosmolar
(concentrated) state.
 Blood glucose may rise as high as 1500
mg/dL, and electrolyte imbalances occur
 Because ketoacidosis is not present, the
patient may not feel as physically ill as
the patient with DKA and may delay
seeking treatment.
Songoma JM .MUHAS

 Symptoms of HHNK include:
 extreme thirst,
 lethargy, and mental confusion.
 Shock, coma, and death occur if HHNK is
left untreated
 . The mortality rate for HHNK is between 10%
and 20%.
Songoma JM .MUHAS

 THERAPEUTIC INTERVENTION.
 Treatment includes IV fluids and insulin, and
glucose monitoring.
 Electrolytes are closely monitored.
 The cause of HHNK should be identified and
treated. HHNK syndrome can be prevented
with careful monitoring of glucose levels at
home.
 Patients should be instructed to drink plenty
of fluids if blood glucose levels are beginning
to rise, especially in times of stress and
illness.
Songoma JM .MUHAS

 Small blood vessels can become diseased,
eventually leading to retinopathy in most
patients with diabetes.
 Retinopathy involves damage to the tiny
blood vessels that supply the eye.
 Small hemorrhages occur, which can
cause blindness if not corrected. Diabetes
is also associated with a high incidence of
cataracts.
 Patients with diabetes should have a
yearly dilated eye examination
Songoma JM .MUHAS

 . Nephropathy is caused by damage to the
tiny blood vessels within the kidneys. Up
to 40% of patients with diabetes develop
some degree of nephropathy.
 A primary risk factor for diabetic
nephropathy is poor control of blood
glucose
 . Patients should be taught the
importance of blood glucose control to
prevent or delay kidney disease.
Songoma JM .MUHAS

 Neuropathy can cause numbness and pain in the
extremities, erectile dysfunction (impotence) in
males, sexual dysfunction in women,
gastroparesis (delayed stomach emptying), and
other problems. Unfortunately, pain caused by
neuropathy is difficult to treat with traditional
analgesics
 Some antidepressant and anticonvulsant drugs
may be helpful, and in some cases local
injections of anesthetics may be used.
 A new drug, pregabalin (Lyrica), that reduces
painful nerve impulses
Songoma JM .MUHAS

 Persons with diabetes are prone to infection for
several reasons
 If injuries occur, healing may be slow because of
impaired circulation.
 There may not be enough blood supply to heal the
wound or fight an infection
 . In the presence of hyperglycemia, white blood
cells become sluggish and ineffective, further
reducing the body’s ability to fight infection
 . The incidence of periodontal (gum) disease,
caused by bacteria in plaque, is also increased in
individuals with diabetes.
.
Songoma JM .MUHAS

 Individuals with diabetes develop atherosclerosis
and arteriosclerosis faster than the general
population. They are more likely to have
hypertension and elevated low-density lipoprotein
(LDL) cholesterol and triglyceride levels. High blood
glucose may also affect platelet function, leading
to increased clotting.
 These problems lead to a higher incidence of
strokes, heart attacks, and poor circulation in the
feet and legs. The risk of cardiovascular disease and
strokes is two to four times more common in
persons with diabetes than in the general
population.
Songoma JM .MUHAS

 The combination of vascular disease, neuropathy,
and risk for infection makes patients with diabetes
prone to foot problems
 . Consider the patient who has no feeling in his or
her feet because of neuropathy.
 Vascular disease will prevent a good blood supply
from preventing infection and promoting healing
 If infection sets in, it is slow to resolve and may
progress to necrosis and gangrene. Pressure points
on the feet may also break Neuropathy can also
lead t o deformities of the feet, further increasing
the risk for injuries
 . For these reasons, diabetes is the leading cause of
amputation of the lower extremities.
Songoma JM .MUHAS

• History of current problem
• History of stress, illness, virus
• Family history of diabetes
• Current medications
• Other medical or surgical conditions
• Knowledge of diabetes self-care
• Vital signs
• Signs of dehydration
Songoma JM .MUHAS

• Fruity breath
• Presence of complications if suspect diabetes was
undiagnosed for period of time
• History of diabetes:type, onset, duration,degree of
blood glucose control
• Knowledge of selfcare and degree of compliance
• Support systems
• History of complications
• Labs: blood glucose level, HbA1c, BUN, creatinine,
ketones, cholesterol, triglycerides
• Condition of legs and feet; pulses, presence of
circulatory or sensation impairment
Songoma JM .MUHAS

Risk for ineffective health maintenance
related to knowledge deficit in the patient
with newly diagnosed diabetes mellitus
Songoma JM .MUHAS

 Assess knowledge of diabetes
 self-care.Assist patient to collaborate with
health care provider to determine
appropriate blood glucose levels and action
to be taken if glucose levels are too high or
too low.
 Teach patient to assess glucose levels before
meals and at bedtime or as ordered by
health care provider.
 Ensure that patient knows how to obtain
glucose monitor and instruction for home
use.
 Teach patient how to administer insulin or
oral hypoglycemic agent.
Songoma JM .MUHAS

 Ensure that meals are timed appropriately
with medications
 . Replace any uneaten foods to prevent
hypoglycemia. Teach technique for
administering insulin if indicated.
 Observe for symptoms of hypoglycemia and
hyperglycemia and treat as necessary. Teach
causes, prevention, recognition, and
treatment of hypoglycemia and
hyperglycemia
 Consult with dietician for nutrition therapy
instruction. Consult with social worker or
case manager as needed.
Songoma JM .MUHAS

 Does patient exhibit knowledge of diabetes
self-care? Are blood glucose levels within
parameters negotiated with health care
provider?
 Does patient state appropriate blood glucose
levels and action to take if glucose is high or
low?
 Does patient demonstrate correct use of
glucose monitor or state
 how monitor and instruction will be
obtained?
 Does patient state correct meal and
medication schedule?
Songoma JM .MUHAS

 Does patient demonstrate correct
injection technique?
 Does patient state causes, prevention,
symptoms, and treatment
 of hypoglycemia? Does patient carry fast
sugar at all times?
 Is patient able to state plan for obtaining
appropriate meals?
 Does patient state availability of
adequate resources for selfcare
Songoma JM .MUHAS

 William,JS and Hopper , PD(2007) .
Uderstanding Medical –Surgical Nursing 3rd
edition FA Davis company Philidea
Songoma JM .MUHAS

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