Diabetes mellitus

1. DIABETES MELLITUS
MR.V. ATPUTHAVADIVEL
NURSING TUTOR
COLLEGE OF NURSING
BATTICALOA

2. DIABETES MELLITUS
•Diabetes mellitus is a metabolic disorder
characterized by hyperglycemia and results
from defective insulin production,
secretion, or utilization.

3. Classification of diabetes
1. Type 1 diabetes mellitus – was formerly
known as IDDM, Juvenile diabetes mellitus.
a. Little or no endogenous insulin requiring injection of insulin
to control.
b. 5 to 10 % of diabetic patients have type 1.
c . Etiology: autoimmunity, viral, ain genetic
d. Usual presentation is rapid with classic symptoms of
polydipsia, polyphagia, polyuria, and weight loss.
e. Most Commonly seen in patients under age 30
but can seen in older adults.

4. Classification of diabetes….
2. Type 2 diabetes mellitus - was formerly known as NIDDM or
adult onset diabetes mellitus.
a. Insulin resistance and insulin deficiency.
b. Approximately 90% of diabetic patients have type 2.
c. Etiology: hereditary with obesity commonly occurs
persons over age 40.
e. Usually presentation is slow and typically insidious
with symptoms of fatigue, weight gain, poor wound
healing, recurrent infection.’

5. Pathophysiology and Etiology
1. There is an absolute or relative Lack of insulin produced by the beta
cell resulting in hyperglycemia.
2. Defects at the cell level, impaired secretory response of insulin to
rises in glucose, and increased nocturnal hepatic glucose production
(gluconeogenesis) are see in type 2 diabetes.
3. Etiology of type 1 diabetes is not well understood; viral,
autoimmune, and envioromental factors.
4. Etiology of type 2 diabetes involves heredity, genetics, and obesity.

6. Clinical features
Hyperglycemia
1. Weight loss fatigue
2. Polyurea, polydipsia, polyphagia
3. Blurred vision
Others
1. Poor wound healing
2 . Recurrent infection, particularly of the skin

7. Investigation
1. Diabetics can be diagnosed in any of the following ways (and should
be confirmed on a different day by any of these)
a. FBS of greater than or equal to 126 mg/dL
b. RBS of greater than or equal to 200 mg/dL
c. OGTT greater than or equal to 200 mg/dL 2-hour
sample.
- FBS
- 75 g oral glucose
- samples after ½ hour, 1 hour, 2 hour, 3 hour

8. Management
Diet
1. Dietary control with caloric restriction of
CHO and saturated fats.
2. Meal planning is to control blood glucose and lipid
levels

9. Management…
Exercise
- Regularly, scheduled, moderate, atleast 30 minutes
per day

10. Management…
Medication
1. Oral antidiabetic agents for patients
with type 2 diabetes.
2. Insulin therapy for patients with type I diabetes who
require replacement.
• May also be used for type 2 diabetes when unresponsive to diet,
exercise, and oral antidiabetic therapy.

11. Medication…

12. Medication….

13. Medication…

14. Medication…

15. Complications
• Acute
1. Hypoglycemia.
2. DKA
3. Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) –
type 2 DM, severe dehydration, hyperglycemia, hyperosmolarity,
and stupor.

16. Complications….
• Chronic
1. In type I diabetes, chronic complications usually appear about 10
years after the initial diagnosis.
2. Microvascular complications - retinopathy, nephropathy and
neuropathy is higher in type I diabetes.
3. Cardiovascular disease - occurring in type 1 and type 2 diabetes are
the leading cause of morbidity and mortality

17. Nursing Assessment
• Obtain history of current problem, family history, and
general health history.
• Polyuria, polydipsia, polypagia and other symptoms?
• Number of years since diagnosis of diabetes.
• Family numbers diagnosis with diabetes, treatment and
complication.

18. Nursing Assessment…..
• Perform physical examination to assess sign and
symptoms and presence of complication.
• Skin lesions, dehydration, poor wound healing.
• Eye – change in vision, cataract, glucoma.
• Mouth – gingivitis, periodontal disease.
• Cardiovascular – orthostatic hypotension, cold extremities,
weak pulse, leg claudication.
• GI – diarrhea, constipation, early satiety, increased flatulence.
• GU – Impotence, vaginal discharge.
• Neurologic – Numbness of extremities, gait change

19. Nursing Diagnoses
• Impaired Nutrition:More than Body Requirements.
• Fear related to insulin injection.
• Risk for Injury (hypoglycemia) related to effects of insulin.
• Activity Intolerance related to poor glucose control.
• Deficient Knowledge related to use of oral hypoglycemic agents.
• Risk for Impaired Skin Integrity related to decreased sensation and
circulation to lower extremities.
• Ineffective Coping related to chronic disease.

20. Nursing intervention
Improving nutrition
• Assess current timing and content of meals.
• Advise patient on the importance of an individualized meal
plan in meeting weight-loss goals. Reducing intake of
carbohydrates may benefit some patients; however, fad diets
or diet plans that stress one food group and eliminate another
are generally not recommended.
• Discuss the goals of dietary therapy for the patient. Setting a
goal of a 10% (of patient’s actual body weight) weight loss over
several months is usually achievable and effective in reducing
blood sugar and other metabolic parameters.

21. Nursing intervention
Improving nutrition…
• Assist patient to identify problems that may have an impact on dietary
adherence and possible solutions to these problems.
• Emphasize that lifestyle changes should be maintainable for life.
• Explain the importance of exercise in maintaining/reducing body weight.
a. Caloric expenditure for energy in exercise.
b. Carryover of enhanced metabolic rate and efficient food utilization.
• Assist patient to establish goals for weekly weight loss and incentives to assist in
achieving them.
• Strategize with patient to address the potential social pitfalls of weight
reduction.

22. Nursing intervention…..
Teaching about insulin
• Assist patient to reduce fear of injection by encouraging verbalization of fears
regarding insulin injection, conveying a sense of empathy, and identifying
supportive coping techniques.
• Demonstrate and explain thoroughly the procedure for insulin self-injection
• Help patient to master technique by taking a step-by-step approach.
a. Allow patient time to handle insulin and syringe to become familiar with
the equipment.
b. Teach self-injection first to alleviate fear of pain from injection.
c. Instruct patient in filling syringe when he or she expresses confidence in
self-injection procedure.
• Review dosage and time of injections in relation to meals, activity, and bedtime based on
patient’s individualized insulin regimen.

23. Teaching about insulin….

24. Teaching about insulin….

25. Nursing intervention…..
Preventing injury secondary to hypoglycemia
• Closely monitor blood glucose levels to detect hypoglycemia.
• Instruct patient in the importance of accuracy in insulin preparation and meal
timing to avoid hypoglycemia.
• Assess patient for the signs and symptoms of hypoglycemia.
a. Adrenergic (early symptoms)—sweating, tremor, pallor, tachycardia,
palpitations, nervousness from the release of adrenalin when blood glucose
falls rapidly.
b. Neurologic (later symptoms)—light-headedness, headache, confusion,
irritability, slurred speech, lack of coordination, staggering gait from
depression of central nervous system as glucose level progressively falls.

26. Nursing intervention…..
Preventing injury secondary to hypoglycemia…
• Treat hypoglycemia promptly...
• One-half cup (4 oz) juice, 1 cup skim milk, three glucose tablets, four
sugar cubes, five to six pieces of hard candy may be taken orally.
• Encourage patient to carry a portable treatment for hypoglycemia at all
times.
• Assess patient for cognitive or physical impairments that may interfere
with ability to accurately administer insulin.
• Between-meal snacks as well as extra food taken before exercise should
be encouraged to prevent hypoglycemia.
• Encourage patients to wear an identification bracelet or card that may
assist in prompt treatment in a hypoglycemic emergency.

27. Nursing intervention…..
Improving activity tolerance
• Advise patient to assess blood glucose level before and after strenuous
exercise.
• Instruct patient to plan exercises on a regular basis each day.
• Encourage patient to eat a carbohydrate snack before exercising to avoid
hypoglycemia.
• Advise patient that prolonged strenuous exercise may require increased food at
bedtime to avoid nocturnal hypoglycemia.
• Instruct patient to avoid exercise whenever blood glucose levels exceed 250
mg/day and urine ketones are present. Patient should contact health care
provider if levels remain elevated.
• Counsel patient to inject insulin into the abdominal site on days when arms or
legs are exercised.

28. Nursing intervention…..
Providing information about oral anti diabetic agent
• Identify barriers to learning, such as visual or hearing
impairments, low literacy, distractive environment.
• Encourage active participation of the patient and family in the
educational process.
• Teach the action, use, and adverse effects of oral antidiabetic
agents
• Identify financial barriers to accessing medications and follow-
up care. Offer resources such as Partnership for Prescription
Assistance

29. Nursing intervention…..
Maintaining Skin Integrity
• Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns,
calluses, dryness, hammertoe or bunion deformation, hair distribution, pulses,
deep tendon reflexes.
• Maintain skin integrity by protecting feet from breakdown.
a. Use heel protectors, special mattresses, foot cradles for patients on bed rest.
b. Avoid applying drying agents to skin (eg, alcohol).
c. Apply skin moisturizers (preferably creams) to maintain suppleness and prevent cracking
and fissures.

30. Nursing intervention…..
Maintaining Skin Integrity…
• Instruct patient in foot care guidelines.
• Advise the patient who smokes to stop smoking, or reduce if possible, to reduce
vasoconstriction and enhance peripheral blood flow. Help patient to establish
behavior modification techniques to eliminate smoking in the hospital and to
continue them at home for smoking-cessation program.

31. Nursing intervention…..
Improving Coping Strategies
• Discuss with the patient the perceived effect of diabetes on
lifestyle, finances, family life, occupation.
• Explore previous coping strategies and skills that have had
positive effects.
• Encourage patient and family participation in diabetes selfcare
regimen to foster confidence.
• Identify available support groups to assist in lifestyle adaptation.
Refer to a certified diabetes educator.
• Assist family in providing emotional support.

32. Health education
• Regular follow up clinic…………
• Teach pt checking fingerstick glucose & urine sugar…..
• Teach pt self administration of insulin……..
• Instruct pt to maintaining good body hygiene specially foot
care.
• Instruct pt to keep all time a handy source of glucose / sugar.
• Teach and provide guideline of meal planning.
• Ongoing education of pt about treatment, prevention and
management of complication

33. THANK YOU