Diabetes mellitus

Ekta S Patel, Assistant Professor, Sumandeep Nursing College, SVDU.
DIABETES MELLITUS
By,
Ekta S Patel
Assistant Professor.

•Insulin is a hormone which plays a key role in the
regulation of blood glucose levels.
•A lack of insulin, or an inability to adequately respond to
insulin, can each lead to the development of the
symptoms of diabetes.
•In addition to its role in controlling blood sugar levels,
insulin is also involved in the storage of fat.

THE ROLE OF INSULIN INTHE BODY
•Insulin is a hormone which plays a number of roles in the
body’s metabolism.
•Insulin regulates how the body uses and stores glucose
and fat.

Insulin and blood glucose levels
• Insulin helps control blood glucose levels by signaling the
liver, muscle and fat cells to take in glucose from the blood.
• Insulin therefore helps cells to take in glucose to be used for
energy.
• If the body has sufficient energy, insulin signals the liver to
take up glucose and store it as glycogen.
• The liver can store up to around 5% of its mass as glycogen.

Introduction:

•Diabetes mellitus is a group of metabolic disease in
which defects in insulin secretion or action result in
elevated blood glucose.

Magnitude of problem.
•World Diabetes DAY is observed on
14 November every year to create
global awareness.

•According to the International Diabetes Federation (IDF),
there are 422 million people living with diabetes around
the world.
•India had more diabetes than any other country in the
world.
•Diabetes currently affects more than 62 million Indians
which is more than 7.1% of the adult population, average
age on onset is 42.5 years.
•Nearly 1 million Indians die due to diabetes every year.

•India is the diabetes capital
of the world and Kerala is
the diabetes capital of India
with a prevalence of 20%.

•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 amputations.
•With good education and self -care, patients with diabetes
can prevent or delay these complications and lead full,
productive lives.
•Nurses play a major role in helping patients learn to care
for themselves effectively.

Definition:
•It is group of metabolic disorders and heterogeneous
disorder characterized by high level of blood glucose
resulting from defect in insulin secretion or action or
both.
•A disease in which the body’s ability to produce or
respond to the hormone insulin is impaired, resulting in
abnormal metabolism of carbohydrates and elevated
levels of glucose in the blood.

TYPES AND CAUSES
TYPE 1: DIABETES MELLITUS
• Type1 diabetes (formerly called juvenile diabetes
mellitus, insulin-dependent diabetes mellitus or
IDDM) is caused by destruction of the beta cells in the
islets of Langerhans of the pancreas.

•When the beta cells are destroyed, they are unable to
produce insulin.
•Insulin must then be injected for the body to use food for
energy.
•The pancreas may attack itself following certain viral
infections or administration of certain drugs.
•This is called an autoimmune response.

• Almost 90% of patients newly diagnosed with type1 diabetes
have islet cell antibodies in their blood.
• These antibodies might be present for years before actual
systems of diabetes develop.
• About 10% of people with type1 diabetes causes also have a
genetic preposition to its development.
• The patient with type1 diabetes is most often young and
thin and is prone to develop ketoacidosis when blood
glucose is elevated.

•Diabetic ketoacidosis (DKA)
•is a life-threatening problem that affects people with
diabetes. It occurs when the body starts breaking down
fat at a rate that is much too fast. The liver processes the
fat into a fuel called ketones, which causes the blood to
become acidic.

TYPE 2: DIABETES MELLITUS
•95% of people with diabetes have type 2 diabetes mellitus
(formerly called adult-onset diabetes mellitus,
noninsulin-dependent diabetes mellitus or NIDDM).

•In type 2 diabetes mellitus, 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.

•As the disease advances, the pancreas eventually wears
out, and insulin production decrease.
•When this occurs, the patient will likely require insulin
injections.

Comparison of type 1 and type 2 diabetes
Type 1 Type 2
Onset Rapid Slow
Age at onset Usually younger than 40 Usually older than 40
Risk factors Virus, autoimmune response,
heredity
Heredity, obesity
Usual body type Lean Obese
High blood glucose
complication
ketoacidosis Hyperosmolar
hyperglycemic state, may
develop ketoacidosis
Treatment Diet, exercise, must have insulin
to survive
Diet, exercise, may need oral
hypoglycemic agents or
insulin to control blood
glucose level.

GESTATIONAL DIABETES
•Gestational diabetes mellitus (GDM) occurs in 2 to 10%
of pregnancies.
•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 a 35 to 60% risk of developing type 2
diabetes within 10 to 20 years.
•If the mother with GDM is overweight, she should be
counselled that weight loss and exercise will decrease her
risk of developing diabetes.

PREDIABETES:
•Prediabetes refers to blood glucose levels that are above
normal but do not meet the criteria for diagnosing
diabetes.
•Prediabetes usually occurs before the onset of type 2
diabetes.

•It is diagnosed by evaluating fasting blood glucose levels,
glucose tolerance tests or HbA1c. those with prediabetes
may be able to prevent the onset of diabetes with weight
loss and exercise.

OTHERTYPE DIABETES
•Secondary diabetes can develop as a result of another
chronic illness that damage 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 can also impair insulin action and raise blood
glucose.
•Less common causes include pancreatic trauma and other
endocrine disorders.

Pathophysiology of DM:

SIGNS AND SYMPTOMS
• Classic symptoms of diabetes mellitus include 3Ps-
•polydipsia (excessive thirst),
•polyuria(excessive urination), and
•polyphagia(excessive hunger).

•The large amount of glucose in the blood causes an
increase in serum concentration or osmolality.
•The renal tubules are unable to reabsorb all the excess
glucose i.e filtered by the glomeruli and glycosuria
results .
•Large amounts of body water are required to excrete this
glucose causing polyuria, nocturia (night time urination)
, and dehydration cause polydipsia.

•Because glucose is unable to enter the cells, the cells
starve causing polyphagia.
•High blood glucose can also cause fatigue, blurred vision,
abnormal pain and headaches.
•Ketones(acidic byproducts of fat break down) can
buildup in the blood and urine of patients with type 1
diabetes or late in the course of type 2 diabetes
(ketoacidosis)

DIAGNOSTICTESTS
Fasting Plasma Glucose Level:
• Diagnosis of diabetes mellitus is based on plasma glucose
levels measured by a laboratory.
• According to the American Diabetes Association
(ADA,2014), a normal plasma glucose level is less than
100mg/dl.
• When the fasting plasma glucose (drawn after at least 8 hours
without eating) is 126mg/dl or grater, 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
125mg/dl, the patient has impaired fasting glucose (IFG)
and prediabetes.

Random Plasma Glucose :
•Sometimes it is not feasible to check a fasting plasma
glucose.
•A random plasma glucose (RPG) is checked without
regard to the last meal.
•Diabetes is diagnosed if the RPG is 200mg/dl or greater
with symptoms of diabetes.

Glycohemoglobin:
•The glycohemoglobin test [also called glycosylated
haemoglobin or HbA1c ( haemoglobin A1C)] is used to
gather baseline data and to monitor the progress of
diabetes control.
•In 2009, the ADA also changed its guidelines to include
the HbA1c as a diagnostic test for diabetes.
•Glucose in the blood attaches to haemoglobin in the red
blood cells which live about 3 months.

•When the glucose that is attached to the haemoglobin is
measured, it reflects the average blood glucose level for
the previous 2 to 3 months.
•This is a helpful measurement when blood glucose levels
fluctuate and a single measurement would be misleading.
•It also assists in determining the degree of effectiveness
of a patient’s treatment plan.
•A normal HbA1c is 4 to 6%. An HbA1c of 6.5% or higher
is diagnostic for diabetes.
•An HbA1c between 6 and 6.5% indicates high risk for
developing diabetes ( prediabetes).

Post-Prandial Blood Sugar (2-hour
PPBS)
•After the patient fasts for 12 hours, a meal is given which
contains starch and sugar (approx. 100 gm).
•Then after 2 hours blood is collected to measure glucose
level.
•Home blood sugar test is the most common way to check
2-hour postprandial blood sugar levels.

Oral glucose tolerance test (OGTT)
•Glucose Tolerance is defined as the capacity of the body
to tolerate an extra load of glucose or it measures the
body's ability to use glucose.
•It is series of blood glucose measurements taken after
drink glucose liquid
•It is considered as definitive diagnostic test for DM.

•It is ordered to:
Confirm the diagnosis, in pre-diabetic
Diagnose gestational diabetes (most commonly)
Recommended if 100-126 mg/dL (5.5 mmol/L-7.0
mmol/L)

Urine analysis for glycosuria

•Urine ketone body test

•Capillary blood glucose test

Connecting Peptide / C-Peptide:
•This test measures the level of C-peptide in your blood
or urine.
•C-peptide is a substance made in the pancreas, along
with insulin.
•Body doesn't make the right amount of insulin, it may be
a sign of diabetes.
• C-peptide and insulin are released from the pancreas at
the same time and in about equal amounts.

Therapeutic Measures:
•There is no cure for diabetes.
•However, diabetes can be controlled.
•Treatment begins with diet and exercise.
•Insulin is added in patients with type 1 diabetes or oral
hypoglycemic medication as needed in those with type 2
diabetes.

•Weight loss is essential for patients who have 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.

Goals of Treatment:
•The ADA recommends that patients maintain a pre-
prandial (premeal) plasma glucose level of 70-130 mg/dl,
peak postprandial glucose less than 180 mg/dl and
glycohemoglobin levels of less than 7% to prevent or
delay complications of diabetes.
•Because of the risk for cardiovascular disease , they also
recommends maintaining blood pressure of less than
140/80 mm Hg (ADA,2014).

NutritionTherapy :
•The goal of nutrition therapy is to achieve and maintain
blood glucose and lipid levels as near to normal as
possible to prevent long – term complications.
•Because the patient with diabetes has a limited amount
of insulin either endogenous (from within the body) or
injected, it is important to eat an amount of food that will
not exceed the insulin’s ability to carry it into the cells.

•This requires a meal plan that includes consistent
amounts of carbohydrates, protein and fats each day.
•Because carbohydrates contribute most to the blood
glucose level, it is important that the amount of
carbohydrates consumed is consistent from one day to the
next.
•If a patient eats a small amount of carbohydrate one day
and a large amount the next, the blood glucose will
fluctuate leading to complications.

Exercise:
•Exercise lowers blood glucose by improving the
sensitivity of muscles to insulin and the effects can last
upto 48 hours.
•Exercise also improves blood lipid levels and circulations
which is important for the person with diabetes who
already has an increased risk of cardiovascular disease.
•Patients are instructed to engage in moderate exercise at
least 150 minute per week, spread over at least 3 days of
the week.

Medication :
Injected Insulin:
•The person with type 1 diabetes has no endogenous insulin and
therefore must inject insulin daily.
•Insulin is typically given subcutaneously, fast- acting insulin may
be ordered via the intramuscular or intravenous (Iv) route in
urgent situations.
•Several types of insulin are available with various schedules by
which they may be given.
•The type and schedule are determined based on the patient’s
lifestyle and willingness to spend time on injections.

Site Rotation:
•Insulin injections should be given in a different
subcutaneous site with each dose to avoid tissue injury.
•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 area.
•Within that area, each injection should be spaced at least
1 inch from the previous injection.
•Aspirating for blood before injection and rubbing the site
after injection are not recommended with insulin
injections.

Insulin Pumps :
• Patients who desire tighter control of blood glucose levels and a more
flexible lifestyle may choose to use an insulin pump.
• A pump delivers subcutaneous insulin via a tiny catheter continuously
in small (basal) amounts.
• The catheter is placed in subcutaneous tissue and remains in place for 2
to 3 days.
• The patient can then add a bolus of insulin with the push of a button
before meals or snacks.
• This provides insulin levels that are more normal like those of a person
without diabetes.
• A pump typically is worn on the abdomen or buttocks.
• Some models receive input from continuous glucose monitors.

Oral Hypoglycemic Medications :
• The patient with type 2 diabetes may be able to control blood glucose
levels with medical nutrition therapy and exercise alone.
• If needed , orally hypoglycemic medication or insulin will also be
prescribed.
• Orally hypoglycemic agents are not insulin pills but work in ways
such as stimulating the pancreas to produce more insulin or making
the tissues more sensitive to insulin.
• More oral hypoglycemic agents should be administered 30 minutes
before meals.
• If the blood glucose level is not controlled with an oral hypoglycemic
agent, insulin may be needed for the person with type 2 diabetes.

• Oral Hypopglycemic Medications
• Sulfonylureas (glipizide, glyburide, gliclazide, glimepiride)
• Meglitinides (Repaglinide and nateglinide)
• Biguanides (Metformin)
• Thiazolidinediones (rosiglitazone, pioglitazone)
• α-Glucosidase inhibitors (acarbose, miglitol, voglibose)
• DPP-4 inhibitors (sitagliptin, saxagliptin, vildagliptin,
linagliptin, alogliptin)
• SGLT2 inhibitors (dapagliflozin and canagliflozin)
• Cycloset (Bromocriptine)

Self- Monitoring of Blood Glucose :
•The ability to test blood glucose levels at home has been
a major advance in diabetes care.
•Blood glucose can be better controlled because of the
availability of monitoring at any time, in any place.
•A variety of blood glucose monitors are on the market at
reasonable prices.
•Most of the cost involved in monitoring is in the test
strips that must be used.

•Health insurance programs may cover this cost.
•New devices are available that continuously monitor
glucose via a small catheter inserted into the abdomen.
•The device records the glucose level every 5 minutes on a
monitor that is worm-like a pager on a belt.
•It can be set to alarm if the blood glucose level drops too
low.

Complications of diabetes :
•Complications related to high and low blood glucose
levels are described as follows:

Hyperglycemia
•When calories eaten exceed insulin available or glucose
used, high blood glucose (hyperglycemia) occurs.
•A Common cause of hyperglycemia is eating more than
the meal plan prescribes.
•Another major cause is stress.
•Stress causes the release of counter regulatory hormons,
including epinephrine, cortisol, growth hormone and
glucagon.
•These hormones increase the blood glucose level.

Hypoglycemia
•Low blood glucose or hypoglycaemia occurs when there
is not enough glucose available in relation to circulating
insulin.
•This is sometimes referred to as an insulin reaction.
•Hypoglycemia is usually defined as a blood glucose level
below 70 mg/dl, although patients may feel symptoms at
higher or lower levels.
•Cause of hypoglycaemia may include skipping a meal,
exercising more than usual or accidentally administering
too much insulin.

•Symptoms of hypoglycaemia include hunger, sweating,
pallor, tremor , palpitations and headache.
•These symptoms are caused by activation of the sympathetic
nervous symptom.
•As hypoglycaemia progresses, the brain is deprived of
glucose (called neuroglycopenia) and neurologic symptoms
such as irritability, confusion, seizures and coma may occur.
•To treat low blood glucose, administer a ‘fast sugar’ -15 to
20 g of carbohydrate that will enter the bloodstream quickly.
•If the patient is not alert or is unable to safely swallow,
subcutaneous glucagon can be given.

•If the patient is hospitalized, IV 50% Dextrose can be
administered by the registered nurse ( RN ).
•Recheck the blood glucose in 15 minutes.
•If it does not return to at least 70 mg/dl , repeat the
procedure every 15 minutes until 70 mg/dl is reached –
even if the patient is feeling better .
•Do not over treat hypoglycaemia with too much sugar
because this may cause hyperglycemia and rebound
hypoglycaemia.
•All people with diabetes should be instructed to keep a fast
sugar in their purse or pocket at all times. Fast sugars may
also be stored in beside tables, cars and desks at work.

Diabetic ketoacidosis :
• Diabetic ketoacidosis (DKA) occurs when blood glucose
levels become very high and insulin is deficient .
• When there is insufficient insulin to allow glucose into cells,
the cells starve.
• The body then breaks down fat to be used for energy.
• The fat break down releases an acid substance called ketones.
• As ketones build up in the blood, ketoacidosis occurs.
• The body attempts to compensate for acidosis by deepening
respirations to blow off excess carbon dioxide.

•Because carbon dioxide combines with water in the body
to form carbonic acid , blowing off carbon dioxide is like
blowing off acid.
•The deep, sighing respiratory pattern is called
kussmaul’s respirations.
•The expired air has a fruity odor caused by the ketones
and may be mistaken for alcohol.

•With such high blood glucose and the accompanying
polyuria, the body becomes dehydrated very quickly.
•Tachycardia, hypotension and shock can result.
•Acidosis also causes potassium to leave the cells and
accumulate in the blood.
•Potassium is then lost in large amounts in the urine which
can lead to hypokalemia.

•The combination of dehydration, potassium imbalance,
and acidosis causes the to develop flu-like symptoms,
including abdominal pain and vomiting.
•The patient loses consciousness and death occurs if DKA
is not treated. The mortality rate for DKA is about 2%.

Therapeutic Measures:
•Treatment includes IV fluids, IV insulin, and blood
glucose monitoring, often initially in an intensive care
unit setting.
•Glucose is added to the IV when the blood glucose drops
to about 180 mg/dl to avoid glycemia.
•Potassium should also be monitored closely because it is
essential to have normal levels for cardiac function.
•Arterial blood gases help monitor acidosis. The cause of
the DKA should be identified and treated.

•Prevention of ketoacidosis involves careful monitoring of
blood glucose levels at home.
•Teach patient to use a urine dipstick to check for ketone
(ketostix) if blood if blood glucose is elevated.
•If ketones are present in patient, the patient should drink
water and recheck with the next urination.
•If ketones are still present , the physician should be
notified.
•Instruct patients never to stop their insulin without a
physician’s supervision.

Long -Term Complications :
• Over time, chronic hyperglycemia causes a variety of serious
complications in person with diabetes.
• These involve the circulatory system, eyes, kidneys, skin and
nerves.
• Most of the complications involve either the large blood
vessels in the body (macrovascular complications) or the tiny
blood vessels, such as those in the eyes or kidneys (
microvascular complications).

Macrovascular Complications :
Circulatory System:
• People with diabetes develop atherosclerosis and
arteriosclerosis faster than the general population.
• They are more likely to have hypertension and elevated low-
density lipoprotein cholesterol and triglyceride levels.
• High blood glucose can also affect platelet function leading
to increase 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.
•Control of blood glucose, blood pressure, and cholesterol
levels is vital to help prevent these deadly complications.
•Patients should also avoid smoking, maintain normal
weight and exercise regularly.

Microvascular complications:
Eyes:
•Small blood vessels can become disease, 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 a leading cause of blindness in
adults.

Kidneys:
•Nephropathy is caused by damage to the tiny blood
vessels in 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.
•If nephropathy occurs, the kidneys are unable to remove
waste products and excess fluid from the blood.
•Diabetes is the leading cause of end stage renal (kidney)
disease (ESRD)

Nerve Complications :
•Another complication of diabetes is neuropathy, which
damages nerves as a result of chronic hyperglycemia.
•Neuropathy can cause numbness and pain in the
extremities, erectile dysfunction(impotence) stomach
emptying) and other problems. Unfortunately, pain
caused by neuropathy is difficult to treat with traditional
analgesic.

•Some antidepressant and anticonvulsant drugs may be
helpful and, in some cases, local injections of
anaesthetics may be used.
•Anticonvulsant agents such as gabapentin (Neurontin)
and pregabalin (Lyrica) reduces painful nerve impulses in
individuals with nerve pain.
•Improved control of blood glucose levels may also help.

Infection:
• 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.
• For the same reasons, it may difficult for IV antibiotics to
reach an infected site and topical antibiotics may be
preferable.

•The incidence of periodontal (gum) disease caused by
bacteria in plaque is also increased in individuals with
diabetes.
•Patients must be taught to maintain good oral hygiene and
make regular visits to the dentist.

Foot Complications:
•The combination of macrovascular 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.
•If the patient has a foot injury, it may not be felt right
away.
•Vascular disease will prevent a good blood supply from
preventing infection and promoting healing.

•For these reasons, diabetes is the leading cause of
nontraumatic amputation of the lower extremities.
•Teach patients to protect their feet at all times by wearing
well fitting shoes and by washing, drying and inspecting
their feet daily.
•If any sores are noted, the patient should not delay in
seeking treatment.

• During routine visits to the physician, teach the patient to be
sure to remove shoes and socks to the feet can be thoroughly
examined.
• The physician or diabetes specialist can test sensation in the
feet with tiny filaments.
• Loss of protective sensation is an early risk factor for
amputation, so any reduction in sensation is a warning sign
that extra care must be taken.
• A podiatrist (foot doctor) can be consulted if problems occur.

Foot CareTips
• Wash and dry feet every day. Use warm (not hot) water to
avoid burns.
• Apply lotion that does not contain alcohol, avoiding areas
between toes.
• Inspect feet for sores or red areas daily (have a family
member help if necessary).
• Report any abnormalities immediately.
• Wear leather shoes and white or light-coloured cotton socks.

•Never go barefoot.
•Avoid garters and tight socks. Avoid crossing leg.
•Cut toenails to natural shape of nail- not into corners.
•See a podiatrist for calluses or problem toenails.
•Have fee checked at least once a year, preferably three to
four times a year for loss of sensations.

Special Considerations for the Patient
Undergoing Surgery
• Surgery is a stressor.
• The counter regulatory hormones released during stress cause
the blood glucose to rise, even if the patient has been fasting.
• High blood glucose levels interfere with immune function
and healing and can increase the patient’s risk for infection.
• Patients who were no previously on insulin may be place on
insulin during surgery and postoperatively.
• They can generally return to their presurgical treatment plan
after the stress of surgery is past.

Nursing Management
• Assessment is important to identify potential problems
that have lead to changes in blood glucose level as well as
handle any conflict that may appear during nursing care.

Diabetes mellitus

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Ähnlich wie Diabetes mellitus

Ähnlich wie Diabetes mellitus (20)

Mehr von Ekta Patel

Mehr von Ekta Patel (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Diabetes mellitus