Nursing Management for Diabetes Mellitus

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1. DIABETES MELLITUS
Nelia S. Bañaga – Perez RN, MSN, MAEd
Northeastern College
Nursing Department
Santiago City, Philippines

2. DIABETES MELLITUS
•An endocrine disorder in which there is
insufficient amount or lack of insulin secretion
to metabolize carbohydrates.
•It is characterized by hyperglycemia, glycosuria
and ketonuria.

5. Diabetes Mellitus
Pathophysiology
•The beta cells of the Islets of Langerhan of the
Pancreas gland are responsible for secreting
the hormone insulin for the carbohydrate
metabolism.
•Remember the concept - sugar into the cells.

6. Diabetes Mellitus
Types
•Type 1 - IDDM
–little to no insulin
produced
–20-30% hereditary
–Ketoacidosis
•Gestational
–overweight; risk for Type
2
•Type 2 - NIDDM
–some insulin produced
–90% hereditary
•Other types include Secondary Diabetes :
–Genetic defect beta cell or
insulin
–Disease of exocrine pancreas
–Drug or chemical induced
–Infections-pancreatitits
–Others-steroids,

7. INSULIN
•Insulin is a protein made of 2 chains- alpha and beta
•Preproinsulin is produced initially
–Precursor molecule that is inactive
–Must be made smaller before becoming active
•Proinsulin
–Precursor that includes alpha and beta chains
–Also has a C-peptide chain
–C-peptide levels are used to measure rate that beta cells
secrete insulin

8. INSULIN
•Insulin allows glucose to move into cells to make energy
•Liver is first major organ to be reached
–Promotes production and storage of glycogen (glycogenisis)
–Inhibits glycogen breakdown into glucose (glycogenolysis)
–Increases protein and lipid synthesis
–Inhibits tissue breakdown by inhibiting liver glycogenolysis
(ketogenesis- converts fats to acids) & gluconeogenisis
(conversion of proteins to glucose)
–In muscle, promotes protein and glycogen synthesis
–In fat cells, promotes triglyceride storage

9. INSULIN
•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

10. GLUCOSE HOMEOSTASIS
•Glucose is main fuel for CNS
•Brain cannot make or store, therefore needs
continuous supply
•Fatty acids can be used when glucose is not
available ( triglycerides)
•Need 68-105 mg/dL to support brain
•Decreased levels of glucose, insulin release is
stopped with glucagon released

11. GLUCOSE
•Glucagon causes release of glucose from liver
–Liver glucose is made thru glycogenolysis (glucogen to
glucose) &
–Gluconeogenesis
•When liver glucose is not available, lypolysis
occures ( breakdown of fat) OR
•Proteinlysis (breakdown of amino acids)

12. ABSENCE OF INSULIN
•Insulin needed to move glucose into cells
•Without insulin, body enters a state of
breaking down fats and proteins
•Glucose levels increase (hyperglycemia)

13. Absence of Insulin
•Hyperglycemia
•Polyuria
•Polydipsia
•Polyphagia
•Hemoconcentration, hypervolemia,
hyperviscosity, hypoperfusion, and hypoxia
•Acidosis, Kussmaul respiration
•Hypokalemia, hyperkalemia, or normal
serum potassium levels

14. Assessment
•History
•Blood tests
–Fasting blood glucose test: two tests > 126 mg/dL
–Oral glucose tolerance test: blood glucose > 200 mg/dL
at 120 minutes
–Glycosylated hemoglobin (Glycohemoglobin test) assays
–Glucosylated serum proteins and albumin
•FSBS – (finger stick) monitoring blood sugar

15. Urine Tests
•Urine testing for ketones
•Urine testing for renal function
•Urine testing for glucose

16. Diabetes Mellitus
Clinical Manifestation
•Hyperglycemia
–Three P’s -
•Polyuria
•Polyphagia
•Polydispsia
•Gradual Onset
•Hypoglycemia
–Weak, diaphoretic, sweat,
pallor, tremors, nervous,
hungry, diplopia, confusion,
aphasia, vertigo, convulsions
–Treatment - OJ with sugar, or
IV glucose
•Sudden onset

23. Hyperglycemia - Clinical
Manifestations
•Three P’s – polyuria,
polydypsia,
polyphagia
•Glycosuria
•Dehydration
•Hypotension
•Mental Changes
•Fever
•Hypokalemia
•Hyponatremia
•Seizure
•Coma
Life Threatening!!!

27. Risk for Injury Related to
Hyperglycemia
•Interventions include:
–Dietary interventions, blood glucose
monitoring, medications
–Oral Drugs Therapy
(Continued)

28. Risk for Injury Related to
Hyperglycemia (Continued)
–Oral therapy
•Sulfonylurea agents
•Meglitinide analogues
•Biguanides
•Alpha-glucosidase inhibitors
•Thiazolinedione antidiabetic agents

29. Oral Hypoglcemias
Key Points
•Monitor serum glucose levels
•Teach patient signs and symptoms of
hyper/hypoglycemia
•Altered liver, renal function will affect medication
action
•Avoid OTC meds without MD approval
•Assess for GI distress and sensitivity
•Know appropriate time to administer med

31. Diet Therapy
•Goals of diet therapy
•Principles of nutrition in diabetes
–Protein, fats and carbohydrates, fiber,
sweeteners, fat replacers
–Alcohol
–Food labeling
–Exchange system, carbohydrate counting
–Special considerations for type 1 and type 2
diabetes

32. Diabetes Mellitus
Diet
•American Diabetic
Association
•Food groups/ exchanges
•Carbohydrates - 60%
•Fats - 30%
•Protein - 12-20%

33. Diabetes - Monitoring Glucose
Levels
•Urine - Ketones
•FSBS
•Wear ID Bracelet

34. Diabetes - Treatment
Exercise
•Purpose - controls blood
glucose and lowers
blood glucose
•Purpose - reduce the
amount of insulin
needed

35. Exercise Therapy
•Benefits of exercise
•Risks related to exercise
•Screening before starting exercise program
•Guidelines for exercise
•Exercise promotion

37. Drug Therapy
•Drug administration
•Drug selection
•Insulin therapy:
–Insulin analogue
–Short-acting insulin
–Concentrated insulin
–Intermediate
(Continued)

38. Drug Therapy (Continued)
–Fixed-combination
–Long-acting
–Buffered insulins

40. Insulin Regimens
•Single daily injection protocol
•Two-dose protocol
•Three-dose protocol
•Four-dose protocol
•Combination therapy
•Intensified therapy regimens

42. Pharmacokinetics of Insulin
•Injection site
•Absorption rate
•Injection depth
•Time of injection
•Mixing insulins

44. Complications of Insulin Therapy
•Hypoglycemia
•Lipoatrophy
•Dawn phenomenon
•Somagyi's phenomenon

46. Alternative Methods of Insulin
Administration
•Continuous subcutaneous infusion of insulin
•Implanted insulin pumps
•Injection devices
•New technology includes:
–Inhaled insulin
–Transdermal patch (being tested)

47. Client Education
•Storage and dose preparation
•Syringes
•Blood glucose monitoring
•Interpretation of results
•Frequency of testing
•Blood glucose therapy goals

50. Diabetic Education -
Preventive Medicine
•Proper skin and foot
care
•Proper Eye Exam
•Proper diet and fluids
•Diabetic Neuropathy
•Diabetic Retinopathy
•Diabetic Nephropathy
•Diabetic gastroparesis

52. Diabetes Mellitus
Complications
•Hyperglycemia
•Hypoglycemia
•Diabetic Ketoacidosis
•Hyperosmolar Hyperglycemic Nonketotic
Syndrome

53. Acute Complications of Diabetes
•Diabetic ketoacidosis
•Hyperglycemic-hyperosmolar-nonketotic
syndrome
•Hypoglycemia from too much insulin or too
little glucose

54. Diabetic Ketoacidosis

55. Potential for Diabetic Ketoacidosis
•Interventions include:
–Monitoring for manifestations
–Assessment of airway, level of consciousness,
hydration status, blood glucose level
–Management of fluid and electrolytes
(Continued)

56. Potential for Diabetic Ketoacidosis
(Continued)
–Drug therapy goal: to lower serum glucose by 75
to 150 mg/dL/hr
–Management of acidosis
–Client education and prevention

57. Complication – Ketoacidosis
Treatment
•Patent airway
•Suctioning
•Cardiac monitoring
•Vital Signs
•Central venous pressure
•Blood work – ABG, BS,
chemistry panel
•Administration of Na
Bicarb
•Foley – monitor urinary
output
•I & O
•Frequent Repositioning

59. Complication – HHNC
Hyperosmolar Hyperglycemic
Non-Ketotic Coma
•Fluid moves from inside to
outside cell vausing diuresis
and loss of Na+ and K+
•Treatment - Give insulin and
correct fluid and
electrolytes imbalance
•Signs and Symptoms
–Hypotension
–Mental changes
–Dehydration
–Hypokalemia
–Hyponatremia
–Life Threatening!!!

60. Chronic Complications of Diabetes
•Cardiovascular disease
•Cerebrovascular disease
•Retinopathy (vision) problems
•Diabetic neuropathy
•Diabetic nephropathy
•Male erectile dysfunction

64. Diabetes Mellitus
Nursing Process
•Assessment – Medicines, Allergies, Symptoms, Family Hx
•Nursing Diagnosis- Anxiety and Fear, Altered Nutrition, Pain,
Fluid Volume Deficit
•Planning – Address the nursing diagnosis
•Implementation – Prevent complications, monitor blood
sugars, administer meds and diet, teach diet and meds, Asess
, Assess, Assess
•Evaluation- Goals, EOC’s

65. Whole-Pancreas Transplantation
•Operative procedure
•Rejection management
•Long-term effects
•Complications
•Islet cell transplantation hindered by limited
supply of beta cells and problems caused by
antirejection drugs

66. Risk for Delayed Surgical Recovery
•Interventions include:
–Preoperative care
–Intraoperative care
–Postoperative care and monitoring includes care
of:
•Cardiovascular
•Renal
•Nutritional

67. Risk for Injury Related to Sensory
Alterations
•Interventions and foot care practices:
–Cleanse and inspect the feet daily.
–Wear properly fitting shoes.
–Avoid walking barefoot.
–Trim toenails properly.
–Report nonhealing breaks in the skin.

68. Wound Care
•Wound environment
•Debridement
•Elimination of pressure on infected area
•Growth factors applied to wounds

69. Chronic Pain
•Interventions include:
–Maintenance of normal blood glucose levels
–Anticonvulsants
–Antidepressants
–Capsaicin cream

70. Risk for Injury Related to Disturbed Sensory
Perception: Visual
•Interventions include:
–Blood glucose control
–Environmental management
•Incandescent lamp
•Coding objects
•Syringes with magnifiers
•Use of adaptive devices

71. Ineffective Tissue Perfusion: Renal
•Interventions include:
–Control of blood glucose levels
–Yearly evaluation of kidney function
–Control of blood pressure levels
–Prompt treatment of UTIs
–Avoidance of nephrotoxic drugs
–Diet therapy
–Fluid and electrolyte management

72. Potential for Hypoglycemia
•Blood glucose level < 70 mg/dL
•Diet therapy: carbohydrate replacement
•Drug therapy: glucagon, 50% dextrose,
diazoxide, octreotide
•Prevention strategies for:
–Insulin excess
–Deficient food intake
–Exercise
–Alcohol

73. Potential for Hyperglycemic-Hyperosmolar
Nonketotic Syndrome and Coma
Interventions include:
Monitoring
Fluid therapy: to rehydrate the client
and restore normal blood glucose
levels within 36 to 72 hr
Continuing therapy with IV regular
insulin at 10 units/hr often needed to
reduce blood glucose levels

74. Health Teaching
•Assessing learning needs
•Assessing physical, cognitive, and emotional
limitations
•Explaining survival skills
•Counseling
•Psychosocial preparation
•Home care management
•Health care resources

76. Diabetes Mellitus
Summary
•Treatable, but not curable.
•Preventable in obesity, adult client.
•Diagnostic Tests
•Signs and symptoms of hypoglycemia and
hyperglycemia.
•Treatment of hypoglycemia and hyperglycemia – diet
and oral hypoglycemics.
•Nursing implications – monitoring, teaching and
assessing for complications.

77. DIABETES SELF CARE STAR
• MEALS


MONITORING
* PLASMA
*FEET
MEDICATIONS
*INSULIN
*ORAL
AGENTS
MANAGEMENT
*SICK DAY
*HYPOGLYCEMIA
* HYPERGYCEMIA
MOTION