CHAPTER I

INTRODUCTION

A. Background

Diabetes mellitus is a growing health problem, particularly in developed countries. Global

projections of diabetes estimate that by 2010 the total number of individuals with diabetes
will be 239.3 million worldwide, with 23.7 million people with type 1 diabetes and 215.6
million with type 2 [1]. This is double the number estimated in 1994. In Australia, there were
an estimated 700,000 people with diabetes in 1995, of which at least half were unaware they
had the condition [2]. This figure is expected to rise to 950,000 by 2010.

Type 2 diabetes is the most common form of diabetes and constitutes the majority of cases
worldwide. It comprises 85-90% of all diabetes cases, making it a significant public health
issue in the majority of developed countries [3]. There is an increasing body of evidence to
suggest that type 2 diabetes is a consequence of increasing levels of obesity, decreased levels
of activity, and increased food availability – a result of 'modernisation'. Societies undergoing
transition to western lifestyles (such as hunter-gatherer societies) are potentially at the
greatest risk for developing diabetes. In this context, the prevalence of diabetes among some
Indigenous Australians is among the highest in the world. This has been attributed at least in
part to lifestyle changes associated with transition from a traditional to western diet

With a population of 237.6 million people in 2010, Indonesia is the world’s fourth
most populated country. It also has the seventh largest number of diabetic patients (7.6
million), despite relatively low prevalence (4.8% including both diabetes type 1 and 2 in
individuals aged 20–79 years) in 2012

Due to the potentially devastating effects of the diabetes epidemic to the development of
the Indonesian health system and complications, treatment, and outcomes of diabetes in
Indonesia and its implications on the current health system developments.

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B. Purpose
1. General Purpose
The general objective of this paper is expected to manufacture the student is able to
provide nursing care in patients with diabetes mellitus

2. Specific Purpose
Students are expected to:
1. Explaining the sense of diabetes mellitus
2. Mention the type of diabetes mellitus
4.Describe the etiology of diabetes mellitus
5. Describe the signs and symptoms of diabetes mellitus
6. Explain the complications of diabetes mellitus
7. Describe the Diagnostic Studies
8. Describe the treatment of diabetes mellitus
9. Describe the Assesment of diabetes mellitus
10 Describe the nursing care in patients with diabetes mellitus

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 CHAPTER II
DISCUSSION

A. DEFINITION

Diabetes mellitus is a metabolic disorder characterized by hyperglycemia

(high blood sugar). Diabetes is a disease in which the body doesn't produce or
properly use insulin. Insulin is a hormone produced in the pancreas, an organ near the
stomach. Insulin is needed to turn sugar and other food into energy.

Diabetes mellitus is a condition in which the pancreas no longer produces

enough insulin or cells stop responding to the insulin that is produced, so that glucose
in the blood cannot be absorbed into the cells of the body.

Diabetes mellitus, often simply referred to as diabetes—is a group of metabolic

diseases in which a person has high blood sugar, either because the body does not
produce enough insulin, or because cells do not respond to the insulin that is
produced. This high blood sugar produces the classical symptoms of polyuria
(frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).

B. TYPE OF DIABETES
There are three main types of diabetes :

 Type 1 diabetes: results from the body's failure to produce insulin, and presently
requires the person to inject insulin. (Also referred to as insulin-dependent diabetes
mellitus, IDDM for short, and juvenile diabetes.)
 Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use
insulin properly, sometimes combined with an absolute insulin deficiency.
 Gestational diabetes: is when pregnant women, who have never had diabetes before,
have a high blood glucose level during pregnancy. It may precede development of
type 2 DM.

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 Other forms of diabetes mellitus include congenital diabetes, which is due to genetic
defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced
by high doses of glucocorticoids, and several forms of monogenic diabetes.
All forms of diabetes have been treatable since insulin became available in
1921, and type 2 diabetes may be controlled with medications. Both type 1 and 2 are
chronic conditions that usually cannot be cured. Pancreas transplants have been tried
with limited success in type 1 DM; gastric bypass surgery has been successful in
many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after
delivery. Diabetes without proper treatments can cause many complications. Acute
complications include hypoglycemia, diabetic ketoacidosis, or nonketotic
hyperosmolar coma. Serious long-term complications include cardiovascular disease,
chronic renal failure, retinal damage. Adequate treatment of diabetes is thus
important, as well as blood pressure control and lifestyle factors such as smoking
cessation and maintaining a healthy body weight

C. CAUSES

The cause of diabetes depends on the type. Type 2 diabetes is due primarily to
lifestyle factors and genetics. The risk of diabetes is higher if there is a family history
of diabetes. Environmental factors that can lead to the onset of diabetes include poor
diet, lack of exercise, obesity, and stress. Diabetes is a disease that can be prevented –
or controlled once a diagnosis has been made.

Type 1 diabetes is also partly inherited and then triggered by certain infections, with
some evidence pointing at Coxsackie B4 virus. There is a genetic element in
individual susceptibility to some of these triggers which has been traced to particular
HLA genotypes (i.e., the genetic "self" identifiers relied upon by the immune system).
However, even in those who have inherited the susceptibility, type 1 diabetes mellitus
seems to require an environmental trigger.

Gestational diabetes, During pregnancy the placenta makes hormones that can lead to
a buildup of sugar in your blood. Usually, your pancreas can make enough insulin to
handle that. If not, your blood sugar levels will rise and can cause gestational diabetes

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 D. RISK FACTOR
There is no known cause for the onset of diabetes. However, there are certain factors
that place a person at higher risk of contracting diabetes.
The risk factors of diabetes can include:
 A family history of diabetes
 Obesity
 Poor diet
 Physical inactivity

E. SIGNS AND SYMPTOMS

The classical symptoms of diabetes are Unexplained weight loss polyuria

(frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).
Symptoms may develop rapidly (weeks or months) in type 1 diabetes while in type 2
diabetes they usually develop much more slowly and may be subtle or absent.

Prolonged high blood glucose causes glucose absorption, which leads to changes
in the shape of the lenses of the eyes, resulting in vision changes; sustained sensible
glucose control usually returns the lens to its original shape. Blurred vision is a
common complaint leading to a diabetes diagnosis; type 1 should always be suspected
in cases of rapid vision change, whereas with type 2 change is generally more gradual,
but should still be suspected.

People (usually with type 1 diabetes) may also present with diabetic ketoacidosis,
a state of metabolic dysregulation characterized by the smell of acetone; a rapid, deep
breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and
an altered states of consciousness.

A rarer but equally severe possibility is hyperosmolar nonketotic state, which is

more common in type 2 diabetes and is mainly the result of dehydration. Often, the
patient has been drinking extreme amounts of sugar-containing drinks, leading to a
vicious circle in regard to the water loss.

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 Sores that take longer than usual to heal and A number of skin rashes can occur in
diabetes that are collectively known as diabetic dermadromes.

F. COMPLICATION
Long-term complications of diabetes develop gradually. The longer you have diabetes
and the less controlled your blood sugar the higher the risk of complications.
Eventually, diabetes complications may be disabling or even life-threatening.
Possible complications include:
 Cardiovascular disease. Diabetes dramatically increases the risk of various
cardiovascular problems, including coronary artery disease with chest pain (angina),
heart attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes,
you are more likely to have heart disease or stroke.
 Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood
vessels (capillaries) that nourish your nerves, especially in your legs. This can cause
tingling, numbness, burning or pain that usually begins at the tips of the toes or
fingers and gradually spreads upward. Left untreated, you could lose all sense of
feeling in the affected limbs. Damage to the nerves related to digestion can cause
problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to
erectile dysfunction.
 Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel
clusters (glomeruli) that filter waste from your blood. Diabetes can damage this
delicate filtering system. Severe damage can lead to kidney failure or irreversible end-
stage kidney disease, which may require dialysis or a kidney transplant.
 Eye damage (retinopathy). Diabetes can damage the blood vessels of the retina
(diabetic retinopathy), potentially leading to blindness. Diabetes also increases the
risk of other serious vision conditions, such as cataracts and glaucoma.
 Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the
risk of various foot complications. Left untreated, cuts and blisters can develop
serious infections, which often heal poorly. These infections may ultimately require
toe, foot or leg amputation.
 Skin conditions. Diabetes may leave you more susceptible to skin problems,
including bacterial and fungal infections.

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  Hearing impairment. Hearing problems are more common in people with diabetes.
 Alzheimer's disease. Type 2 diabetes may increase the risk of Alzheimer's disease.
The poorer your blood sugar control, the greater the risk appears to be. Although there
are theories as to how these disorders might be connected, none has yet been proved.

Complications of gestational diabetes

Most women who have gestational diabetes deliver healthy babies. However,
untreated or uncontrolled blood sugar levels can cause problems for you and your
baby.
Complications in your baby can occur as a result of gestational diabetes,
including:
 Excess growth. Extra glucose can cross the placenta, which triggers your baby's
pancreas to make extra insulin. This can cause your baby to grow too large
(macrosomia). Very large babies are more likely to require a C-section birth.
 Low blood sugar. Sometimes babies of mothers with gestational diabetes
develop low blood sugar (hypoglycemia) shortly after birth because their own
insulin production is high. Prompt feedings and sometimes an intravenous
glucose solution can return the baby's blood sugar level to normal.
 Type 2 diabetes later in life. Babies of mothers who have gestational diabetes
have a higher risk of developing obesity and type 2 diabetes later in life.
 Death. Untreated gestational diabetes can result in a baby's death either before or
shortly after birth.
Complications in the mother can also occur as a result of gestational diabetes,
including:
 Preeclampsia.This condition is characterized by high blood pressure, excess
protein in the urine, and swelling in the legs and feet. Preeclampsia can lead to
serious or even life-threatening complications for both mother and baby.
 Subsequent gestational diabetes. Once you've had gestational diabetes in one
pregnancy, you're more likely to have it again with the next pregnancy. You're
also more likely to develop diabetes — typically type 2 diabetes — as you get
older.

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 G. DIAGNOSTIC STUDIES

 Serum glucose: Increased 200–1000 mg/dL or more.

 Serum acetone (ketones): Strongly positive.
 Fatty acids: Lipids, triglycerides, and cholesterol level elevated.
 Serum osmolality: Elevated but usually less than 330 mOsm/L.
 Glucagon: Elevated level is associated with conditions that produce (1) actual
hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of
insulin. Therefore, glucagon may be elevated with severe DKA despite
hyperglycemia.
 Glycosylated hemoglobin (HbA1C): Evaluates glucose control during past 8–12
wk with the previous 2 wk most heavily weighted. Useful in differentiating
inadequate control versus incident-related DKA (e.g., current upper respiratory
infection [URI]). A result greater than 8% represents an average blood glucose of
200 mg/dL and signals a need for changes in treatment.
 Serum insulin: May be decreased/absent (type 1) or normal to high (type 2),
indicating insulin insufficiency/improper utilization (endogenous/exogenous).
Insulin resistance may develop secondary to formation of antibodies.
 Electrolytes:
 Sodium: May be normal, elevated, or decreased.
 Potassium: Normal or falsely elevated (cellular shifts), then markedly
decreased.
 Phosphorus: Frequently decrease
 Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO3
(metabolic acidosis) with compensatory respiratory alkalosis.
 CBC: Hct may be elevated (dehydration); leukocytosis suggest
hemoconcentration, response to stress or infection.
 BUN: May be normal or elevated (dehydration/decreased renal perfusion).
 Serum amylase: May be elevated, indicating acute pancreatitis as cause of
DKA.
 Thyroid function tests: Increased thyroid activity can increase blood glucose
and insulin needs.

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  Urine: Positive for glucose and ketones; specific gravity and osmolality
may be elevated.

 Cultures and sensitivities: Possible UTI, respiratory or wound infections.

H. NURSING CARE PLAN FOR DIABETES MELLITUS

Assessment

Assessment of patients with diabetes mellitus (Doenges, 1999) include:

a. Family Health History

Are there families who suffer from illnesses such as client ?
b. Patient Health History and Previous Treatment
How long suffered from DM client, how to handle, get what kind of
insulin therapy, how to take the medicine whether regular or not, what is
done to cope with illness clients.
c. Activity / Rest
Symptoms: weakness, fatigue, difficulty moving / walking, muscle
cramps, decreased muscle tone.
Signs: decreased muscle strength.
d. Circulation
Symptoms: ulcers on the legs, a long healing process, tingling / numbness
in the extremities.
Signs: skin hot, dry and reddish.
e. Ego integrity
Symptoms: depend on others.
Signs: anxiety, sensitive stimuli.
f. Elimination
Symptoms: changes in the pattern of urination (polyuria), nocturia
Signs: dilute urine, pale dry, poliurine.
g. Food / fluid
Symptoms: loss of appetite, nausea / vomiting, do not follow the diet,
weight loss.Symptoms: dry skin / scaly, ugly turgor.

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 h. Pain / comfort
Symptoms: pain in the ulcer wound
Signs: face grimacing with palpitations, looks very carefully.
i. Security
Symptoms: dry skin, itching, skin ulcers.
Symptoms: fever, diaphoresis, damaged skin, lesion / ulceration
j. Counseling / learning
Symptoms: family risk factors diabetes, heart disease, stroke,
hypertension, long healing. The use of drugs such as steroids, diuretics
(thiazides): diantin and phenobarbital (may increase blood glucose levels).

Nursing Diagnosis for Diabetes Mellitus

Nursing diagnoses in patients with diabetes mellitus (Doenges, 1999) are:

1. Fluid Volume Deficit related to osmotic diuresis, gastric loss, excessive diarrhea,
nausea, vomiting, limited input, mental mess.
2. Imbalanced Nutrition, Less Than Body Requirements related to insulin
insufficiency, decreased oral input: anorexia, nausea, a full stomach, abdominal
pain, change in consciousness: hypermetabolism status, the release of stress
hormones.
3. Risk for Infection related to inadequate peripheral defense, changes in circulation,
high blood sugar levels, invasive procedures and skin damage.
4. Fatigue related to decreased metabolic energy production, changes in blood
chemistry, insulin insufficiency, increased energy demand, hypermetabolism
status status / infection.
5. Knowledge Deficit: about condition, prognosis and treatment needs related to
misinterpretation of information / do not know the source of information.

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 Nursing Intervention and Implementation
for Diabetes Mellitus
Intervention is planning nursing actions that will be implemented to address the problem
in accordance with the nursing diagnoses.

Implementation is the realization of management and nursing plans that had been
developed at the planning stage.

Nursing Intervention and implementation in patients with diabetes mellitus (Doenges,

1999) include:

1).Fluid Volume Deficit

Expected outcomes:
Patients showed an improvement in fluid balance,
the criteria; spending adequate urine (normal range), vital signs stable, clear peripheral
pulse pressure, good skin turgor, capillary refill well and mucous membranes moist or
wet.
Intervention / Implementation:

1. Monitor vital signs, note the presence of orthostatic blood pressure.

R: Hypovolemia can be manifested by hypotension and tachycardia.
2. Assess breathing and breath patterns.
R: The lungs secrete carbonic acid is produced through respiration compensated
respiratory alkalosis, the state of ketoacidosis.
3. Assess temperature, color and moisture.
R: Fever, chills, and diaphoresis is common in the infection process. Fever with skin
redness, dry, maybe a picture of dehydration.
4. Assess peripheral pulses, capillary refill, skin turgor and mucous membranes.
R: Is an indicator of the level of dehydration or adequate circulating volume.
5. Monitor intake and output. Record the urine specific gravity.
R: Provide the estimated need for fluid replacement, renal function and the
effectiveness of a given therapy.

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 6. Measure body weight every day.
R: Provide the best results of the assessment of the status of ongoing fluid and further
in giving replacement fluids.
7. Collaboration fluid therapy as indicated
R: Type and amount of fluid depends on the degree of dehydration and individual
patient response.

2). Imbalanced Nutrition, Less Than Body Requirements

Goal: weight can be increased with normal laboratory values and no signs of malnutrition.
Expected outcomes:
Patients are able to express an understanding of substance abuse, decrease the amount of
intake (diet on nutritional status).
Demonstrate behaviors, lifestyle changes to improve and maintain a proper weight.
Intervention / Implementation:
1. Measure body weight per day as indicated.
R: Knowing eating adequate income.
2. Determine the diet program and diet of patients compared with food that can be spent
on the patient.
R: Identify deviations from the requirements.
3. Auscultation of bowel sounds, record the presence of abdominal pain / abdominal
bloating, nausea, vomiting, keep fasting as indicated.
R: Influence of intervention options.
4. Observation of the signs of hypoglycemia, such as changes in level of consciousness,
cold / humid, rapid pulse, hunger and dizziness.
R: Potentially life-threatening, which must be multiplied and handled appropriately.
5. Collaboration in the delivery of insulin, blood sugar tests and diet.
R: It is useful to control blood sugar levels.

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 3). Risk for Infection

Goal: Infection does not occur.

Expeected outcomes:
Identify individual risk factors and potential interventions to reduce infection.
Maintain a safe aseptic environment.

Intervention / Implementation
1. Observation for signs of infection and inflammation such as fever, redness, pus in
the wound, purulent sputum, urine color cloudy and foggy.
R: incoming patients with infections that normally might have been able to trigger
a state ketosidosis or nosocomial infections.
2. Increase prevention efforts by performing good hand washing, each contact on all
items related to the patient, including his or her own patients.
R: prevention of nosocomial infections.
3. Maintain aseptic technique in invasive procedures (such as infusion, catheter
folley, etc.).
R: Glucose levels in the blood will be the best medium for the growth of germs.
4. Attach catheter / perineal care do well.
R: Reduce the risk of urinary tract infection.
5. Give skin care with regular and earnest. Massage depressed bone area, keep skin
dry, dry linen and tight (not wrinkled).
R: peripheral circulation can be impaired which puts patients at increased risk of
damage to the skin / eye irritation and infection.
6. Position the patient in semi-Fowler position.
R: Makes it easy for the lung to expand, lowering the risk of hypoventilation.
7. Collaboration antibiotics as indicated.
R: penenganan early can help prevent the onset of sepsis.

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 5. Knowledge Deficit
Goal : patient expressed understanding of the conditions, procedures and effects of the
treatment process.
Expected outcomes:
Perform the necessary procedures and explain the rationale of an action.
Initiate the necessary lifestyle changes and participate in treatment regimen.

Intervention / Implementation:

1. Assess the level of knowledge of the client and family about the disease.
R: Find out how much experience and knowledge of the client and family about the
disease.
2. Give an explanation to the client about diseases and conditions now.
R: By knowing the diseases and conditions now, clients and their families will feel
calm and reduce anxiety.
3. Encourage clients and families to pay attention to her diet.
R: Diet and proper diet helps the healing process.
4. Ask the client and reiterated family of materials that have been given.
R: Knowing how much understanding of clients and their families and assess the
success of the action taken.

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 CHAPTER III
CLOSING
Knot

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting

from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of
diabetes is associated with long-term damage, dysfunction, and failure of various organs,
especially the eyes, kidneys, nerves, heart, and blood vessels. Diabetes is a disease that affects
how the body uses glucose, the main type of sugar in the blood. Glucose comes from the foods we eat
and is the major source of energy needed to fuel the body's functions.Lifestyle changes, such as a
healthy meal plan, weight control and physical activity, may help prevent or delay the onset of Type 2
diabetes.

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 REFERENCES

Carpenito-Moyet, L. (2012). Nursing diagnosis: Application to clinical practice (14th ed.).

Philadelphia, PA: Lippincott, Williams, & Williams.

Doenges, M., Moorhouse, M., & Murr, A. (2009). Nursing care plans: Guidelines for
individualizing client care across the life span (8th ed.). Philadelphia, PA: FA Davis
Company.
http://www.biomedcentral.com/1472-6955/12/20

https://www.kaahe.org/health/en/19-preventing-diabetes/19-1-preventing-diabetes-
introduction.html

http://www.uniassignment.com/essay-samples/nursing/understanding-the-diagnosis-of-
diabetes-nursing-essay.php

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