Diabetes mellitus

DIABETES
MELLITUS
JYOTI
1ST YR

What is diabetes?
Diabetes mellitus (DM) is a chronic condition that is
characterized by raised blood glucose levels
(Hyperglycemia).

What is insulin?
• Insulin : is a hormone produced by beta cells of the
islets of Langerhans in the pancreas gland.

Pancreas secretes 40-50 units of insulin daily in two steps:
• Secreted at low levels during fasting ( basal insulin
secretion)
• Increased levels after eating (prandial)
• An early burst of insulin occurs within 10 minutes of
eating
• Then proceeds with increasing release as long as
hyperglycemia is present

Normal Insulin and Glucose level

Physiology of Insulin secretion

Type 1 DM
 Type 1 diabetes is also called insulin-dependent
diabetes.
 It used to be called juvenile-onset diabetes, because it
often begins in childhood.
 It is an autoimmune condition. It's caused by the body
attacking its own pancreas with antibodies.
 In people with type 1 diabetes, the damaged pancreas
doesn't make insulin.
 This type of diabetes may be caused by a genetic
predisposition. It could also be the result of faulty beta
cells in the pancreas that normally produce insulin

Type 2 DM
 The most common form of diabetes is type 2 diabetes,
accounting for 95% of diabetes cases in adults.
 Type 2 diabetes is often a milder form of diabetes than
type 1.
 With Type 2 diabetes, the pancreas usually produces
some insulin. But either the amount produced is not
enough for the body's needs, or the body's cells are
resistant to it.
 Insulin resistance, or lack of sensitivity to insulin,
happens primarily in fat, liver, and muscle cells.

Gestational DM
 It is often diagnosed in middle or late pregnancy. Because
high blood sugar levels in a mother are circulated through
the placenta to the baby.
 Gestational diabetes must be controlled to protect the
baby's growth and development.
 Having gestational diabetes does, however, put mothers at
risk for developing type 2 diabetes later in life.
 With gestational diabetes, risks to the unborn baby are
even greater than risks to the mother.
 Risks to the mother include needing a cesarean section
due to an overly large baby, as well as damage to heart,
kidney, nerves, and eye.

Epidemiology
• It is uncommon in infants, increase in frequency until
adolescence and then drops sharply.
• Diabetes mellitus affects about 17 million people, 5.9
million of whom are undiagnosed. In the United States,
approximately 800,000 new cases of diabetes are
diagnosed yearly.
• Diabetes is especially prevalent in the elderly, with up
to 50% of people older than 65 suffering some degree
of glucose intolerance.
• Seasonal variation has also been noted with children
being diagnosed more often in winter than summer
months.
• Diabetes Mellitus is found most frequently in persons
over 40years of age who are obese and who have a
family history of diabetes.

Diagnostic test for DM
it includes:
 Physical Examination
 Blood glucose 4 types: FBS, PPBS, RBS, OGGT
 Urine Analysis Urine Sugar / Urine Protein /Urine
Microalbumin / Ketones
 HbA1C
 Insulin
 ICA (islent cell antibody) for type I
 KFT
 ECHO

Nursing Diagnoses
• Imbalanced nutrition related to increase in stress
hormones (caused by primary medical problem) and
imbalances in insulin, food, and physical activity
• Risk for impaired skin integrity related to immobility
and lack of sensation (caused by neuropathy)
• Deficient knowledge about diabetes self-care skills
(caused by lack of basic diabetes education or lack of
continuing in-depth diabetes education

How Insuline Decrease Plasma Glucose Level?

Complication if insulin therapy
Local allergy Lipodystrophy
Lipohypertrophy

ACUTE COMPLICATION
1. Hypoglycemia
Hypoglycemia (abnormally low blood glucose level)
occurs when the blood glucose falls to less than 50 to 60
mg/dL . It can be caused by too much insulin or oral
hypoglycemic agents, too little food, or excessive physical
activity. Hypoglycemia may occur at any time of the day
or night. It often occurs before meals, especially if meals
are delayed or snacks are omitted. For example,
midmorning hypoglycemia and Middle-of-the-night
hypoglycemia

Clinical Manifestation:-
• In mild hypoglycemia:-
sweating, tremor, tachycardia, palpitation, nervousness,
and hunger.
• In moderate hypoglycemia:
Concentrate headache, lightheadedness, confusion,
memory lapses, numbness of the lips and tongue, slurred
speech, impaired coordination, emotional changes,
irrational or combative behavior, double vision, and
drowsiness.
• In severe hypoglycemia:-
disoriented behavior, seizures, difficulty arousing from
sleep, or loss of consciousness.

Emergency Measures:-
For patients who are unconscious and cannot swallow,
an injection of glucagon 1 mg can be administered either
subcutaneously or intramuscularly.
Glucagon is a hormone produced by the alpha cells of
the pancreas that stimulates the liver to release glucose
(through the breakdown of glycogen, the stored glucose).
Injectable glucagon is packaged as a powder in 1-mg vials
and must be mixed with a diluent before being injected.
After injection of glucagon, it may take up to 20 minutes
for the patient to regain consciousness.
 In the hospital or emergency department, patients who
are unconscious or cannot swallow may be treated with 25
to 50 mL 50% dextrose in water (D50W) administered
intravenously.

Management :-
Immediate treatment must be given when hypoglycemia
occurs. The usual recommendation is for 15 g of a fast-
acting concentrated source of carbohydrate such as the
following, given orally.
Adding table sugar to juice may cause a sharp increase
in the blood glucose level, and the patient may experience
hyperglycemia for hours after treatment.
 The blood glucose level should be retested in 15
minutes and retreated if it is less than 70 to 75 mg/dL

Patient education:-
• It is important for patients with diabetes, especially
those receiving insulin, to learn that they must carry some
form of simple sugar with them at all times.
•Patients are advised to refrain from eating high-calorie,
high fat dessert foods (eg, cookies, cakes, doughnuts, ice
cream) to treat hypoglycemia.
•The high fat content of these foods may slow the
absorption of the glucose, and the hypoglycemic
symptoms may not resolve as quickly as they would with
the intake of carbohydrates.

2. Diabetic Ketoacidosis
DKA is caused by an absence or markedly inadequate
amount of insulin. This deficit in available insulin results
in disorders in the metabolism of carbohydrate, protein,
and fat. The three main clinical features of DKA are:
• Hyperglycemia
• Dehydration and electrolyte loss
• Acidosis

MANAGEMENT OF DKA
 Restore circulating blood volume and protect against
cerebral, coronary, and renal hypo-perfusion.
 Treat dehydration with rapid IV infusion of 0.9 or
0.45% normal saline (NS) as prescribed; dexotrose is
added to IV fluids when the blood glucose level
reaches 250 to 300 mg/dl.
 Treat hyperglycemia with insulin administered
intravenously as prescribed.
 Correct electrolyte imbalances (potassium level may be
elevated as a result of dehydration and acidosis).
 Monitor potassium level closely

NURSING MANAGEMENT
• Monitor vital signs.
• Monitor urinary output and for signs of fluid overload.
• Stabilize the patient’s airway,breathing,circulation
• Assess cardiac monitoring and pulse oxymetry.
• Monitor serum glucose hourly and urine ketone
• Monitor basic electrolyte,osmolarity and venous PH
every 4 hourly until pt is stable.
• Determine and treat any underlying causes of DKA eg;
pneumonia,UTIand MI.

3. Hyperglycemic Hyperosmolar Nonketotic
Syndrome
• HHNS is a serious condition in which hyperosmolarity
and hyperglycemia predominate, with alterations of the
sensorium.

Clinical manifestation:-
• hypotension,
• profound dehydration (dry mucous membranes, poor
skin turgor),
• tachycardia,
• variable neurologic signs (eg, alteration of sensorium,
seizures, hemiparesis).
• The mortality rate ranges from 10% to 40%,

Diagnostic evaluation:-
• laboratory tests, including
• blood glucose (600 to 1,200 mg/dL)
• electrolytes, BUN,
• complete blood count,
• serum osmolality,
• arterial blood gas analysis.
• Physical Examination for Mental status changes, focal
neurologic deficits, and hallucinations

Medical Management
fluid replacement, correction of electrolyte imbalances,
and insulin administration.
insulin is usually administered at a continuous low rate
to treat hyperglycemia, and replacement IV fluids with
dextrose are administered when the glucose level is
decreased to the range of 250 to 300 mg/dL.
close monitoring of volume and electrolyte status is
important for prevention of fluid overload, heart failure,
and cardiac dysrhythmias.
Central venous or arterial pressure monitoring
Potassium is added to IV fluids when urinary output is
adequate.

Nursing Management :-
• close monitoring of vital signs, fluid status, and
laboratory values.
• prevent injury related to changes in the patient’s
sensorium secondary.
• Fluid status and urine output are closely monitored
because of the high risk for renal failure secondary to
severe dehydration
• careful assessment of cardiovascular, pulmonary, and
renal function important throughout the acute and
recovery phases of HHNS

MACROVASCULAR COMPLICATIONS
Diabetic macrovascular complications result from changes
in the medium to large blood vessels. Blood vessel walls
thicken, sclerose, and become occluded by plaque that
adheres to the vessel walls. Eventually, blood flow is
blocked. Three major macrovascular complications are:-
Coronary artery disease
 Cerebrovascular disease,
peripheral vascular disease

Coronary artery disease
 Myocardial infarction is twice as common in diabetic
men and three times as common in diabetic women.
 . Coronary artery disease may account for 50% to 60%
of all deaths in patients with diabetes.
 One unique feature of coronary artery disease in
patients with diabetes is that the typical ischemic
symptoms may be absent. Thus, patients may not
experience the early warning signs of decreased
coronary blood flow and may have “silent” myocardial
infarctions.
 silent myocardial infarctions may be discovered only as
changes on the electrocardiogram.

Cerebrovascular disease
Cerebral blood vessels are similarly affected by
accelerated atherosclerosis.
 Occlusive changes or the formation of an embolus
elsewhere in the vasculature that lodges in a cerebral
blood vessel can lead to transient ischemic attacks and
strokes.
 People with diabetes have twice the risk of developing
cerebrovascular disease
 recovery from a stroke may be impaired in patients
who have elevated blood glucose levels at the time of and
immediately after a stroke.
symptoms of cerebrovascular disease may be similar to
symptoms of (HHNS or hypoglycemia),

Peripheral vascular disease
 Atherosclerotic changes in the large blood vessels of the
lower extremities are responsible for the increased
incidence (two to three times higher than in non-diabetic
people) of occlusive peripheral arterial disease in patients
with diabetes.
 Signs and symptoms of peripheral vascular disease
include diminished peripheral pulses and intermittent
claudication (pain in the buttock, thigh, or calf during
walking).
 The severe form of arterial occlusive disease in the lower
extremities is largely responsible for the increased
incidence of gangrene and subsequent amputation in
diabetic patients.
 Neuropathy and impairments in wound healing also play
a role in diabetic foot disease.

Management:-
 Prevention and treatment of the commonly accepted risk
factors for atherosclerosis.
 Diet and exercise are important in managing obesity,
hypertension, and hyperlipidemia.
 The use of medications to control hypertension and
hyperlipidemia may be indicated.
 Smoking cessation is essential.
 Control of blood glucose levels may reduce triglyceride
levels and can significantly reduce the incidence of
complications.
 When macrovascular complications do occur, treatment is
the same as with nondiabetic patients.
 patients may require increased amounts of insulin or may
need to switch from oral antidiabetic agents to insulin
during illnesses.

MICROVASCULAR COMPLICATION
Although macrovascular atherosclerotic changes are
seen in both diabetic and non-diabetic patients, the
microvascular changes are unique to diabetes. Diabetic
microvascular disease (or microangiopathy) is
characterized by capillary basement membrane
thickening. Changes in the microvasculature include :-
Micro-aneurysms
intraretinal hemorrhage,
 hard exudates,
 focal capillary closure.

1. DIABETIC RETINOPATHY
Diabetic retinopathy is retinopathy (damage to the retina)
caused by complications of diabetes mellitus, which can
eventually lead to blindness. It is an ocular manifestation of
systematic disease which affects up to 80% of all diabetic
patients.

 Retinopathy is a painless process.
 In nonproliferative and preproliferative retinopathy,
blurry vision secondary to macular edema occurs in
some patients.
 Hemorrhaging include floaters or cobwebs in the visual
field, or sudden visual changes including spotty or
hazy vision, or complete loss of vision.
Diagnostic evaluation
 ophthalmoscope
 fluorescein angiography

Nursing Management:-
Education focuses on prevention through -
 regular ophthalmologic examinations
 blood glucose control and self-management of eye care
regimens.
 The effectiveness of early diagnosis and prompt
treatment is emphasized in teaching the patient and
family.
 If vision loss occurs,nursing care must also address the
patient’s adjustment to impaired vision and use of
adaptive devices for diabetes self-care as well as
activities of daily living.

2. DIABETIC NEPHROPATHY
Nephropathy, or renal disease secondary to diabetic
microvascular changes in the kidney, is a common
complication of diabetes.
About 20% to 30% of people with type 1 or type 2 diabetes
develop nephropathy, but fewer of those with type 2 diabetes
progress to ESRD.
after the onset of diabetes, and especially if the blood
glucose levels are elevated, the kidney’s filtration mechanism
is stressed, allowing blood proteins to leak into the urine. As
a result, the pressure in the blood vessels of the kidney
increases.

 Worsening blood pressure control
 Protein in the urine
 Swelling of feet, ankles, hands or eyes
 Increased need to urinate
 Less need for insulin or diabetes medicine
 Confusion or difficulty concentrating
 Loss of appetite
 Nausea and vomiting
 Persistent itching
 Fatigue
Diagnostic Test:-
 blood proteins
 urine dipstick test

Management:-
 Maintaining near-normal blood glucose
 Control of hypertension (the use of angiotensin-converting
enzyme [ACE] inhibitors, such as captopril, because control of
hypertension may also decrease or delay the onset of early
proteinuria)
 Prevention or vigorous treatment of urinary tract infections
 Avoidance of nephrotoxic substances.
 Adjustment of medications as renal function changes
 Low-sodium diet
 Low-protein diet
 In chronic or end-stage renal failure, two types of treatment are
available: dialysis (hemodialysis or peritoneal dialysis) and
transplantation.
 Renal disease is frequently accompanied by advancing
retinopathy that may require laser treatments and surgery.

3. DIABETIC NEUROPATHY
Diabetic neuropathy refers to a group of diseases that
affect all types of nerves, including peripheral
(sensorimotor), autonomic, and spinal nerves.
The disorders appear to be clinically diverse and depend
on the location of the affected nerve cells.
The prevalence increases with the age of the patient
The duration of the disease may be as high as 50% in
patients who have had diabetes for 25 years.

Clinical Manifestation:
1.Peripheral neuropathy is the most common form of diabetic
neuropathy. Your feet and legs are often affected first,
followed by your hands and arms. Signs and symptoms of
peripheral neuropathy are often worse at night, and may
include:
• Numbness or reduced ability to feel pain or temperature
changes
• A tingling or burning sensation
• Sharp pains or cramps
• Increased sensitivity to touch — for some people, even the
weight of a bed sheet can be agonizing
• Muscle weakness
• Loss of reflexes, especially in the ankle
• Loss of balance and coordination
• Serious foot problems, such as ulcers, infections,
deformities, and bone and joint pain

2. Autonomic neuropathy:- The autonomic nervous system controls your
heart, bladder, lungs, stomach, intestines, sex organs and eyes. Diabetes
can affect the nerves in any of these areas, possibly causing:
A lack of awareness that blood sugar levels are low (hypoglycemia
unawareness)
Bladder problems, including urinary tract infections or urinary
retention or incontinence
Constipation, uncontrolled diarrhea or a combination of the two
Slow stomach emptying (gastroparesis), leading to nausea, vomiting,
bloating and loss of appetite
Difficulty swallowing
Erectile dysfunction in men
Vaginal dryness and other sexual difficulties in women
Increased or decreased sweating
Inability of your body to adjust blood pressure and heart rate, leading
to sharp drops in blood pressure after sitting or standing that may cause
you to faint or feel lightheaded
Problems regulating your body temperature
Changes in the way your eyes adjust from light to dark
Increased heart rate when you're at rest

3. Radiculoplexus neuropathy (diabetic amyotrophy):-
Radiculoplexus neuropathy affects nerves in the thighs,
hips, buttocks or legs. Also called femoral neuropathy or
proximal neuropathy, this condition is more common in
people with type 2 diabetes and older adults. This
condition is often marked by:
 Sudden, severe pain in your hip and thigh or buttock
 Eventual weak and atrophied thigh muscles
 Difficulty rising from a sitting position
 Abdominal swelling, if the abdomen is affected
 Weight loss

4. Mononeuropathy :- Mononeuropathy involves damage to a
specific nerve. The nerve may be in the face, torso or leg.
Mononeuropathy, also called focal neuropathy, often comes
on suddenly. It's most common in older adults. Although
mononeuropathy can cause severe pain, it usually doesn't
cause any long-term problems. Symptoms usually diminish
and disappear on their own over a few weeks or months.
Signs and symptoms depend on which nerve is involved and
may include:
 Difficulty focusing your eyes, double vision or aching behind
one eye
 Paralysis on one side of your face (Bell's palsy)
 Pain in your shin or foot
 Pain in your lower back or pelvis
 Pain in the front of your thigh
 Pain in your chest or abdomen
 Numbness or tingling in your fingers or hand,
 A sense of weakness in your hand and a tendency to drop
things

Complication:-
1. Loss of a limb
2. Charcot joint.
3. Urinary tract infections and urinary incontinence
4. Hypoglycemia unawareness
5. Low blood pressure.
6. Digestive problems
7. Sexual dysfunction
8. Increased or decreased sweating

Medical Management:-
 analgesics (preferably nonopioid)
 tricyclic antidepressants;
 phenytoin, carbamazepine, or gabapentin (antiseizure
medications);
 (an antiarrhythmic);
 transcutaneous electrical nerve stimulation (TENS).
 Orthostatic hypotension may respond to a diet high in
sodium.
 Treatment of diabetic diarrhea may include bulkforming
laxatives or antidiarrheal agents.
 Constipation is treated with a high-fiber diet and adequate
hydration; medications, laxatives, and enemas may be
necessary when constipation is severe.

Nursing Management:-
 Foot care :- Daily foot care and inspection. Always wear
protective shoes/slippers. Wear good-fitting shoes. Cotton
socks vs nylon socks. Avoid home remedies for corns,
calluses, ingrown toe nails. Cut nail straight across. Avoid
temperature extremes. Seek immediate medical attention
for any injury or problem.
 Fall prevention for postural hypotension
 Prevention of aspiration, attention to hyper/hypoglycemia
with gastroparesis
 Prevention of urinary retention
 Monitor for fixed heart rate with activity.

Diabetes mellitus

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