Diabetes mellitus and diabetes insipidus

1. DIABETES MELLITUS AND
DIABETES INSIPIDUS
PRESENTED BY:
MISS.SHWETA SHARMA
M.SC. NURSING
2nd YEAR
ROLL NO. 5
AIIMS, JODHPUR

2. INTRODUCTION
Diabetes mellitus is characterized by
chronic elevation of glucose in the
blood. It arises because the body is
unable to produce enough insulin for
its own needs, either because of
impaired insulin secretion, impaired
insulin action, or both.

3. EPIDEMIOLOGY
• Major global public health problem
currently affecting 463 million individuals
and projected to affect 700 million by
2045.
• Average age of onset is 42.5 years. Nearly
1 million Indians die due to diabetes every
year.
• In India, 77 million adults currently have
diabetes and this number is expected to
almost double to 134 million by 2045.

5. • Also known as juvenile
diabetes mellitus
• Occurs before 20 years of age
• Insulin dependent diabetes
mellitus [IDDM]
• Occurs due to absolute
deficiency of insulin

6. • Also known as non-insulin
dependent diabetes mellitus
[NIDDM]
• Occurs above 50 years of
age
• Senile diabetes mellitus
• Due to relative deficiency of
insulin
• Insulin is enough in type 2
DM but it may be receptor
deficiency
• It is insulin resistance

7. • Any degree of glucose intolerance with
onset or first recognition during
pregnancy. The definition applies whether
insulin or only diet modification is used for
treatment and whether or not the
condition persists after pregnancy.
•Approximately 7% of all pregnancies are
complicated by GDM, resulting in more
than 2,00,000 cases annually.

21. SIGN AND SYMPTOMS OF GDM

22. DIAGNOSTIC EVALUATION
Type 1 DM
Random blood sugar test. This is the primary screening test for type 1
diabetes. A random blood sugar level of 200 milligrams per decilitre
(mg/dL), or 11.1 millimoles per litter (mmol/L), or higher suggests
diabetes.
Glycated haemoglobin (A1C) test. This test indicates average blood
sugar level for the past three months. Specifically, the test measures
the percentage of blood sugar attached to the oxygen-carrying
protein in red blood cells (haemoglobin). An A1C level of 6.5 percent
or higher on two separate tests indicates diabetes.
Fasting blood sugar test. A fasting blood sugar level of 120 mg/dL or
higher on two separate tests indicates type 1 diabetes.

23. Additional tests:
1. Urine tests to check for presence of ketones, which also suggests
type 1 diabetes rather than type 2
2. Blood and urine tests to check child's:
• Cholesterol levels
• Thyroid function
• Kidney function
In addition, doctor will regularly:
• Assess child's blood pressure and growth
• Check the sites where child tests blood sugar and delivers insulin
• Perform eye examinations

26. Gestational Diabetes Mellitus
Glucose tolerance test or Oral glucose tolerance test (OGTT)
• Ask the patient not to eat or drink anything for at least 8 hours before
the test.
• Before the test begins, a sample of blood will be taken. The patient
will then be asked to drink a liquid containing a certain amount of
glucose (usually 75 grams). Blood sample will be taken again every 30
to 60 minutes after drinking the solution. The test may take up to 3
hours.

28. MANAGEMENT
• The therapeutic goal for diabetes
management is to achieve
normal blood glucose levels
(euglycemia) without
hypoglycemia and without
seriously disrupting the patient’s
usual lifestyle and activity.

29. NUTRITIONAL MANAGEMENT
• Daily dietary planning for diabetic children is important for
prevention of acute or long-term complications and promotion
of growth and development. Diet should be recommended
depending upon the blood sugar level, metabolic status,
standard of living and requirements for growth and
development.

30. While planning the diet: -
• Consider the type of diabetes.
• Consider the present dietary habit.
• Consider activity of the patient.
• Consider time rigidity and flexibility.
• Calculate the requirements of calories as per weight, age and activity.
• Consider any other chronic disease involvement.
• Consider tradition and culture as well as family back ground.

31. Food, Medication and Timing: -
• The food taken by diabetes patients
should preferably be at the same time every
day.
• Patient on insulin injection should balance
food and medicine.
• They should be taught to adjust the timing
of insulin in case of social gathering and
parties.
• The food exchanges for same calories
should be known to all clients.

35. EXERCISE
Benefits:
• Exercise lowers the blood glucose level by increasing the uptake of
glucose by body muscles and by improving insulin utilization.
• It also improves circulation and muscle tone. Resistance (strength)
training, such as weight lifting, can increase lean muscle mass, thereby
increasing the resting metabolic rate.
• Exercise also alters blood lipid levels, increasing levels of high-density
lipoproteins and decreasing total cholesterol and triglyceride levels.
• To avoid post exercise hypoglycemia, especially after strenuous or
prolonged exercise, the patient may need to eat a snack at the end of the
exercise session and at bedtime and monitor the blood glucose level.

36. General Precautions for Exercise in
Diabetics:
• Use proper footwear
• Avoid exercise in extreme heat or cold
• Inspect feet daily after exercise
• Avoid exercise during periods of poor
metabolic control

37. Exercise Recommendations:
• Exercise at the same time (preferably when blood glucose levels are at
their peak) and in the same amount each day.
• Regular daily exercise, rather than sporadic exercise, should be
encouraged.
• Increased blood pressure associated with exercise may aggravate diabetic
retinopathy and increase the risk of a hemorrhage into the vitreous or
retina.
• Patients with ischemic heart disease, risk triggering angina or a myocardial
infarction, which may be silent. Avoiding trauma to the lower extremities is
especially important in the patient with numbness related to neuropathy.
• In general, a slow, gradual increase in the exercise period is encouraged.
• For many patients, walking is a safe and beneficial form of exercise that
requires no special equipment (except for proper shoes) and can be
performed anywhere.

38. MONITORING GLUCOSE LEVELS AND
KETONES
• Blood glucose monitoring is a
cornerstone of diabetes
management, and self-monitoring
of blood glucose (SMBG) levels by
patients has dramatically altered
diabetes care.

39. PHARMACOLOGIC THERAPY
Oral Antidiabetic Agents: 5 classes
• Sulfonylureas- (e.g. gliclazide, glimepiride, meglitinides) are commonly
used as second-line agents in patients with type 2 diabetes.
• Biguanides- Biguanides used with a sulfonylurea may enhance the
glucose-lowering effect more than either medication used alone.
• Alpha glucosidase inhibitors- Acarbose (Precose) and miglitol (Glyset)
are oral alpha glucosidase inhibitors used in type 2 diabetes
management.
• Thiazolidinediones- Rosiglitazone (Avandia) and pioglitazone (Actos)
are oral diabetes medications.
• Meglitinides- Repaglinide (Prandin), an oral glucose-lowering agent.

41. Sliding Scale Therapy
• The term “sliding scale” refers to the progressive increase in
the pre-meal or nighttime insulin dose, based on pre-defined
blood glucose ranges. Sliding scale insulin regimens
approximate daily insulin requirements.

42. The general principles of sliding scale therapy are:
• The amount of carbohydrate to be eaten at each meal is pre-set.
• The basal (background) insulin dose doesn’t change. Patient take
the same long-acting insulin dose no matter what the blood glucose
level.
• The bolus insulin is based on the blood sugar level before the meal
or at bedtime.
• Pre-mixed insulin doses are based on the blood sugar level before
the meal.

44. Complications of Insulin Therapy:
1.Local Allergic Reactions
2.Systemic Allergic Reactions
3.Insulin Lipodystrophy
4.Insulin Resistance
5.Morning Hyperglycaemia

46. ALTERNATIVE METHODS OF INSULIN
INJECTION
A. INSULIN PENS: These devices
use small (150- to 300-unit)
prefilled insulin cartridges that
are loaded into a pen like holder.

47. B. JET INJECTORS: As an alternative
to needle injections, jet injection
devices deliver insulin through the
skin under pressure in an
extremely fine stream.

48. C. INSULIN PUMPS: Continuous subcutaneous insulin infusion involves
the use of small, externally worn devices that closely mimic the
functioning of the normal pancreas. Insulin pumps contain a 3-mL
syringe attached to a long (24- to 42-in), thin, narrow-lumen tube with
a needle or Teflon catheter attached to the end. The patient inserts the
needle or catheter into the subcutaneous tissue (usually on the
abdomen) and secures it with tape or a transparent dressing.

50. SURGICAL MANAGEMENT

52. Ricordi chamber

53. NURSING MANAGEMENT
Teaching Patients to Self-Administer Insulin:
1.With one hand, stabilize the skin by spreading it or pinching up a large
area.
2. Pick up syringe with the other hand and hold it as you would a pencil.
Insert needle straight into the skin.
3. To inject the insulin, push the plunger all the way in.
4. Pull needle straight out of skin. Press cotton ball over injection site for
several seconds.
5.Use disposable syringe only once and discard it.

54. NURSING DIAGNOSIS
• Imbalanced nutrition related to imbalance of insulin, food & physical
activity.
• Fear and anxiety related to long term illness.
• Risk for injury related to hypoglycemia.
• Risk for infection related to hyperglycemic state.
• Risk for fluid volume deficit related to polyuria & dehydration.
• Knowledge deficit related to care of a child/adult with newly diagnosed
diabetes mellitus.

65. DIABETES INSIPIDUS
• Diabetes insipidus (DI) is a condition characterized by large amounts of
dilute urine and increased thirst. The amount of urine produced can be
nearly 20 liters per day.
• "Diabetes insipidus is caused by a deficiency of antidiuretic hormone
(ADH), also known as vasopressin, due to the destruction of the back or
'posterior' part of the pituitary gland where vasopressin is normally
released from, or by an insensitivity of the kidneys to that hormone."

66. EPIDEMIOLOGY
• DI is a rare disease, with a prevalence of 1:25,000. DI can present at any age, and
the prevalence is equal among males and females. The age of presentation
depends on the etiology. Less than 10% of DI is hereditary.
• X-linked nephrogenic DI (NDI) accounts for 90% of cases of congenital NDI and
occurs with a frequency of 4–8/1 million male live births. Autosomal NDI accounts
for approximately 10% of the remaining cases.
• The number of new cases of diabetes insipidus each year is 3 in 100,000. Central
DI usually starts between the ages of 10 and 20 and occurs in males and females
equally. Nephrogenic DI can begin at any age.

67. TYPES AND CAUSES

68. •Central diabetes insipidus
Damage to the pituitary gland or
hypothalamus from surgery, a tumor, a
head injury or an illness can cause central
diabetes insipidus by affecting the usual
production, storage and release of ADH.
An inherited genetic disease can also
cause this condition.

69. • Nephrogenic diabetes insipidus
Nephrogenic diabetes insipidus occurs when
there's a defect in the kidney tubules. This
defect makes kidneys unable to properly
respond to ADH.
• The defect may be due to an inherited
(genetic) disorder or a chronic kidney
disorder. Certain drugs, such as lithium or
antiviral medications such as foscarnet
(Foscavir), also can cause nephrogenic
diabetes insipidus.

70. • Gestational diabetes insipidus
Gestational diabetes insipidus is
rare. It occurs only during
pregnancy when an enzyme made
by the placenta destroys ADH in the
mother.

71. • Primary polydipsia
Also known as dipsogenic diabetes
insipidus, this condition can cause
production of large amounts of diluted
urine. The underlying cause is drinking an
excessive amount of fluids. Primary
polydipsia can be caused by damage to the
thirst-regulating mechanism in the
hypothalamus. The condition has also
been linked to mental illness, such as
schizophrenia.

72. PATHOPHYSIOLOGY

74. CLINICAL MANIFESTATIONS
In adults:
• Extreme thirst
• Producing large amounts of diluted urine
(2 to 20 L/day with specific gravity of less
than 1.005 and urine osmolality of less
than 100 mOsm/kg)
• Frequent need to get up to urinate
during the night
• Preference for cold drinks

75. An infant or young child with diabetes insipidus may have the
following signs and symptoms:
• Heavy, wet diapers
• Bed-wetting
• Trouble sleeping
• Fever
• Vomiting
• Constipation
• Delayed growth
• Weight loss

76. DIAGNOSTIC EVALUATION
• A 24-hour urine collection for
determination of urine volume (2 to 20
L/day)
• Serum electrolyte concentrations and
glucose level
• Urinary specific gravity (less than
1.005)
• Simultaneous plasma and urinary
osmolality
• Plasma ADH level

77. Water deprivation test
• Patient will be asked to stop drinking fluids for several hours. To prevent
dehydration while fluids are restricted, ADH allows kidneys to decrease
the amount of fluid lost in the urine.
• While fluids are being withheld, doctor will measure changes in body
weight, urine output, and the concentration of urine and blood. Doctor
may also measure blood levels of ADH or give synthetic ADH during this
test. This will determine if body is producing enough ADH and if kidneys
can respond as expected to ADH.

79. • ADH test
• After the water deprivation test, the endocrinologist will give a small dose
of ADH, usually as an injection.
• If the dose of ADH causes the body to stop producing urine, it is likely that
the condition is due to a shortage of ADH. If this is the case, patient may
be diagnosed with central diabetes insipidus.
• However, if body continue to produce excess urine despite the dose of
ADH, it suggests that there is already enough ADH in the body, but the
kidneys are not responding to it. In this case, patient may be diagnosed
with nephrogenic diabetes insipidus.

80. •Magnetic
resonance imaging
(MRI)
•Genetic
screening

81. MANAGEMENT
Central diabetes insipidus
• Desmopressin (Minirin). This medication replaces the missing anti-
diuretic hormone (ADH) and decreases urination. This can be taken as a
nasal spray, as oral tablets or by injection. Taking more desmopressin than
you need can cause water retention and potentially serious low-sodium
levels in the blood.
• Other medications may also be prescribed, such as indomethacin
(Indocin, Tivorbex) and chlorpropamide. These drugs can make ADH more
available in the body.

82. Nephrogenic diabetes insipidus
• The doctor may prescribe a low-salt diet to help reduce the amount
of urine kidneys make. Drink enough water to avoid dehydration.
• Treatment with the drug hydrochlorothiazide (Microzide) may
improve symptoms. Although hydrochlorothiazide is a type of drug that
usually increases urine output (diuretic), in some people it can reduce
urine output for people with nephrogenic diabetes insipidus.

83. Gestational diabetes insipidus
• Treatment for most people with gestational diabetes insipidus is with the
synthetic hormone desmopressin.
Primary polydipsia
• There is no specific treatment for this form of diabetes insipidus, other
than decreasing fluid intake. If the condition is related to a mental illness,
treating the mental illness may relieve the diabetes insipidus symptoms.

84. NURSING MANAGEMENT
• Monitor vital signs, neurological and cardiovascular status.
• Provide a safe environment, particularly for the client with a change
in level of consciousness or mental status.
• Monitor electrolyte values and for signs of dehydration.
• Monitor intake and output, weight, and specific gravity of urine.
• Instruct the client to avoid foods or liquids that produce diuresis.

85. • Administer chlorpropamide (Diabinese) if prescribed for mild
diabetes insipidus.
• Administer vasopressin tannate (Pitressin) or desmopressin acetate
(DDAVP,Stimate) as prescribed; these are used when the ADH
deficiency is severe or chronic.
• Instruct the client in the administration of medications as
prescribed (DDAVP may be administered by injection, intranasally, or
orally).
• Instruct the client to wear a Medic-Alert bracelet.

86. Nursing diagnosis
1. Fluid volume deficit related to excessive urinary output as
manifested by increased thirst and hypotension.
2. Disturbed sleep pattern related to nocturia as manifested by
verbalization of patient about interrupted sleep.
3. Activity intolerance related to fatigue and frequent urination as
manifested by weakness and fatigue of the patient.

87. 4. Anxiety related to course of disease and frequent urination as
manifested by verbalization of anxious questions.
5. Ineffective coping related to frequent urination as manifested by
verbalization of negative feeling by the patient.
6. Risk for complications related to excessive loss of fluid from the
body as manifested by hypotension and weight loss.
7. Knowledge deficit related to management of diabetes insipidus as
manifested by verbalization of doubts by the patient.

88. COMPLICATIONS

89. Electrolyte imbalance
Diabetes insipidus can cause an imbalance in electrolytes — minerals
in blood, such as sodium and potassium, that maintain the fluid
balance in body. Symptoms of an electrolyte imbalance may include:
• Weakness
• Nausea
• Vomiting
• Loss of appetite
• Muscle cramps
• Confusion

90. LIFESTYLE AND HOME REMEDIES
• Prevent dehydration. As long as one takes medication and have
access to water when the medication's effects wear off, he/she will
prevent serious problems. Plan ahead by carrying water wherever
going, and keep a supply of medication in travel bag, at work or at
school.
• Wear a medical alert bracelet or carry a medical alert card in
wallet. In case of medical emergency, a health care professional will
recognize immediately the need for special treatment.