Ruchi Saini

Definition
Diabetes mellitus is a syndrome characterized by chronic hyperglycemia and disturbances of carbohydrate, fat & protein metabolism associated with absolute or relative deficiencies in insulin secretion and /or insulin action. Source- Joslins Diabetes mellitus,13th edition

Classification of diabetes mellitus

1. Type 1 diabetes 2. Type 2 diabetes 3. Secondary diabetes 4. Gestational diabetes

Type 1 diabetes
Occur at any age, but usually <30 years Usually thin at diagnosis Can be due to genetic, immunologic or environmental factors Can have islet cell antibodies No endogenous insulin , so require exogenous insulin Diabetic ketoacidosis

Type 2 Diabetes
Onset at age , usually >30 years Usually obese at diagnosis Can be due to hereditary or environmental factors No islet cell antibodies Decreased insulin production or decreased sensitivity to insulin Oral anti-diabetic agents

Secondary diabetes
Genetic defects Diseases of the pancreas Endocrinopathies Drug / chemical induced Infections Genetic syndromes

Gestational Diabetes
Onset usually in 2nd or 3rd trimester Placental hormones reduces action of insulin Treated with diet or insulin

Pre Diabetes mellitus

Impaired glucose tolerance (IGT) ( 2-hour post-glucose load 140 & <200 mg/dl) Impaired fasting glucose 110 & < 126 mg/dl

Risk Factors ?

Clinical Manifestations
D Diuretic symptoms (Polyuria) I Increased infections A Abnormal weight loss B - Blurred vision E Excessive thirst T Tingling or numbness of feet or hands E Extreme hunger

Diagnostic Criteria
Polyuria, Polyphagia , Polydipsia plus plasma glucose concentrations > 200 mg/dl Fasting plasma glucose concentrations > 126 mg/dl 2- hour post-parandial plasma glucose concentration > 200 mg/dl

Pathophysiolo gy

Nutritional Management
Goals Provide nutritional diet Achieve normal blood glucose levels Avoid fluctuations in Normal Blood glucose levels Maintain weight less than 5 % of ideal body weight

Dietary Considerations
BMI Activity level Age / Sex Present food habits Economic status Complications in Diabetes Treatment of Diabetes

Exercise
Provides physical fitness Carbohydrate metabolism Weight & insulin sensitivity Risk factors for cardio-vascular disease Blood pressure & Cardiac work HbAIC

Considerations
Use proper footwear during exercise Avoid exercise in extremes of temperature Inspect feet daily Avoid exercise in periods of poor metabolic control Do not exercise empty or full stomach

Monitoring
A AIC Levels B Blood pressure / Micro albumin C Cholesterol D Diabetic education E Eye Examination F Foot Examination G Blood Glucose Examination H Health I Indications & Referral

Drug s

Oral Hypoglycemic Agents

Insulin

Oral Hypoglycemic Agents

Insulin Therapy

Introduction to Insulin
Hormone Protein Physiological product Used in treatment of Type 1 Diabetes Acute Conditions of Type 2 Diabetes

Onset, Peak and Duration

Onset. The length of time before insulin

reaches the bloodstream and begins lowering blood glucose. Peak time. The time during which insulin is at its maximum strength in terms of lowering blood glucose levels. Duration. How long the insulin continues to lower blood glucose.

Rapid-Acting
Compliments of S. Shaw

Onset of Action Humalog Lispro Novolog Aspart <15 min

Peak Action

Duration of Action

0.5-1.5 hours 4-6 hours

5-10 min

1-3 hours

4-6 hours

Bolus insulin: Taken just before eating

Acting
Compliments of S. Shaw

Onset of Action Humulin R (Regular) Novolin R (Regular) 0.5-1 hours

Peak Action

Duration of Action 6-10 hours

2-3 hours

0.5-1 hours

2-3 hours

6-10 hours

Bolus insulin: Taken 30 minutes before eating

IntermediateActing
Compliments of S. Shaw

Onset of Action NPH 2-4 hours

Peak Action

Duration of action 14-18 hours

4-10 hours

Lente

3-4 hours

4-12 hours

16-20 hours

Basal insulin: Taken usually 1-2 times per day

LongActing
Compliments of S. Shaw

Onset of Action Ultralente 6-10 hours

Peak Action Duration of Action None 20-24 hours

Lantus

1.1 hours

None

24 hours

Basal insulin: Taken 1-2 times per day Dose is based on fasting blood sugar

Delivery Methods
Insulin

Syringe
Insulin Pen Insulin Pump Jet Injector
32

Insulin Injection sites

Complicati ons

ACUTE COMPLICATI ONS

CHRONIC COMPLICATIO NS

Acute complications

Hyperglycemia & Diabetic Keto - acidosis Hyperglycemia Hyperosmolar Non- Ketosis Hypoglycemia

Hyperglyc emia
Diabetic Ketoacidosis HHNS

Chronic Complications

Nursing Management

Nursing Assessment

Nursing Diagnosis
Anxiety Unfamiliar environment Lack of understanding of diagnosis & management Possible changes in life-style & roles

Nursing diagnosis (Contd.)

Altered systemic tissue perfusion Vascular abnormalities Hypovolemia Orthostatic hypotension

Nursing diagnosis (Contd.)

Altered fluid volume deficit Osmotic diuresis Vomiting Diarrhea Diabetic Keto-acidosis

Nursing diagnosis (Contd.)

Altered nutrition : less than body requirements Abnormal glucose metabolism Depletion of fat stores, cellular proteins Decreased oral intake dislike of

Nursing diagnosis (Contd.)

Altered comfort : pain & parathesias , nausea & vomiting , gastric fullness & pyrosis Peripheral neuropathies Vascular insufficiency Visceral irritation due to gastric distension Autonomic neuropathy

Nursing diagnosis (Contd.)

Sensory perceptual alteration Retinopathy Lens changes Neuropathy

Nursing diagnosis (Contd.)

Impaired skin integrity Abnormal pressure distribution due to peripheral neuropathy Delayed wound healing

Nursing diagnosis (Contd.)

Altered : Pattern of urinary elimination Bowel movements Autonomic neuropathy

Nursing diagnosis (Contd.)

Potential for infection High glucose levels Depression of leukocyte function Delayed healing

Nursing diagnosis (Contd.)

Potential for trauma Falls gait abnormalities Burns Sensory perceptual abnormalities Visual disturbances

Nursing diagnosis (Contd.)

Potential for Metabolic complication : Diabetic Ketoacidosis HHNS Hypo-glycemia Hyper - glycemia

Educatio n
Diabetes Mellitus Approaches Of Management Dietary Requirements Exercise Regimen Oral Hypoglycemic Drugs Insulin therapy Complications Foot care Adherence to treatment & Follow-up