Diabetes Mellitus (DM)
Diabetes mellitus is a group of metabolic diseases characterized
by elevated levels of glucose in the blood (hyperglycemia)
resulting from defects in insulin secretion, insulin action, or both
Risks factors
Family history of diabetes (ie, parents or siblings with diabetes)
Obesity (ie, ≥20% over desired body weight or BMI ≥27 kg/m2)
Race/ethnicity (eg, African Americans, Hispanic Americans,
Native Americans, Asian Americans, Pacific Islanders)
Age ≥45 years
Previously identified impaired fasting glucose or impaired glucose
tolerance
Hypertension (≥140/90 mm Hg)
HDL cholesterol level ≤35 mg/dL (0.90 mmol/L) and/or triglyceride
level ≥250 mg/dL (2.8 mmol/L)
History of gestational diabetes or delivery of babies over 9 lbs.
Classification of Diabetes
There are several different types of diabetes mellitus; they may
differ in cause, clinical course, and treatment. The major classifications
of diabetes are:
• Type 1 diabetes (previously referred to as insulin-dependent
diabetes mellitus)
10% of DM; beta cell destruction →little or no insulin for cellular
metabolism of glucose; requires exogenous insulin; Type 1 DM is
associated with specific human leukocyte antigens (HLA), autoantibodies,viruses. Presents at _30yr old
• Type 2 diabetes (previously referred to as non-insulindependent
diabetes mellitus)
• Gestational diabetes mellitus (ADA, Expert Committee on
the Diagnosis and Classification of Diabetes Mellitus,
■90% of DM; ↓sensitivity to insulin (insulin resistance) and ↓secretion of
insulin; may be controlled by diet, exercise, and hypoglycemics; may need
insulin when stressed; Type 2 DM is associated with obesity, genetics,
inactivity, gestational diabetes. Usually presents at _45yr old
NURSING ALERT Ketone bodies are acids that disturb the
acid–base balance of the body when they accumulate in excessive
amounts. The resulting DKA may cause signs and symptoms such
as abdominal pain, nausea, vomiting, hyperventilation, a fruity
breath odor, and, if left untreated, altered level of consciousness,
coma, and death. Initiation of insulin treatment, along with fluid
and electrolytes as needed, is essential to treat hyperglycemia
Etiology and Pathophysiology
Normal glucose metabolism: Blood glucose regulated by insulin andglucagon. Insulin and glucagons are hormones. Glucose is stored asglycogen in liver and muscles or as fat in adipose tissue.
Insulin: Secreted by beta cells in Islets of Langerhans in pancreas. Insulindecreases blood glucose by promoting its entry into cells.
Type 1
■Decreased amount of insulin or ↓response to insulin leads to ↑blood
glucose (hyperglycemia)
■10% of DM; beta cell destruction →little or no insulin for cellular
metabolism of glucose; requires exogenous insulin; Type 1 DM is
associated with specific human leukocyte antigens (HLA), autoantibodies,
viruses. Presents at _30yr old
Type 2
Signs and Symptoms
■The 3 Ps: Polyuria, Polydipsia, Polyphagia (excessive urination, thirst,hunger)
■Fasting blood glucose _126mg/dL, random blood glucose _200mg/dL
■↑Glycosylated hemoglobin (HbA1C) level indicates lack of glucose controlover prior 3mo; glycosuria
■↓Healing
MEDSURG
EDSURG
Alterations in Blood Glucose Associated with DM
1-Hyperglycemia Hypoglycemia
Occurs secondary to stress, omissionof medication, excess food intake;develops over daysS&S: Polyuria; thirst; dry, hot, red
skin; blurred vision; confusion;↑P; ↓BP; S&S of dehydration
2-Hyperglycemic Hyperosmolar
Stress (surgery, infection) and↓insulin →severe hyperglycemia
(_600mg/dL), which →polyuriaand fluid shifts from cells. Results
in dehydration, but not metabolicacidosisS&S: S&S ofhyperglycemia, noketones in urine
3-Somogyi Effect
Hypoglycemia ↑release of epinephrine,corticosteroids, and GH
causing rebound hyperglycemia;hyperglycemia at hs with hypoglycemiaat 2:00 a.m. followed byrebound hyperglycemia in
morning. Requires _insulin.
■Long-term complications:
■Microvascular changes: Retinopathy, neuropathy, nephropathy
(microalbuminuria, ↑BUN, ↑creatinine)
■Macrovascular changes: PVD, ischemic heart disease, cerebral vascularDisease
Treatment
the therapeutic goal for diabetes management is to
achieve normal blood glucose levels (euglycemia) without hypoglycemia
and without seriously disrupting the patient’s usual
lifestyle and activity. There are five components of diabetes management
• Nutritional management
• Exercise
• Monitoring
• Pharmacologic therapy
• Education
Treatment varies because of changes in lifestyle and physical
and emotional status as well as advances in treatment methods.
Therefore, diabetes management involves constant assessment
and modification of the treatment plan by health professionals
and daily adjustments in therapy by the patient.
■Regular exercise to control weight and ↓insulin resistance
■↓Calorie diet (50-60% carbohydrates, 20% protein, 20-30% fat) based on
glycemic food index; ↑soluble fiber →slow glucose absorption
■Insulin and/or oral hypoglycemics
■Pancreatic or Islets of Langerhans transplants
■Treatment of DKA and HHNS: IVF, rapid acting insulin, eventual Na and K†replacement
■Treatment of hypoglycemia: 10-15g of simple sugar followed by complexcarbohydrate and protein if conscious; glucagon injection or 50% dextroseIV if unconscious.
Complications of Insulin Therapy
LOCAL ALLERGIC REACTIONS
A local allergic reaction (redness, swelling, tenderness, and induration
or a 2- to 4-cm wheal) may appear at the injection site 1
to 2 hours after the insulin administration.
SYSTEMIC ALLERGIC REACTIONS
Systemic allergic reactions to insulin are rare. When they do
occur, there is an immediate local skin reaction that gradually
spreads into generalized urticaria (hives).
INSULIN LIPODYSTROPHY
Lip dystrophy refers to a localized reaction, in the form of either
lipoatrophy or lipohypertrophy, occurring at the site of insulin
injections.
NursingMeasures
■Monitor S&S
■Provide foot care:
■Inspect daily for lesions
■Wash/dry between toes daily, wear socks and well-fitting shoes, avoidheat/cold
■Encourage weight control efforts and need for continued medicalsupervision (certified diabetic educator, dietician
■Provide emotional support
■Teach self-monitoring of blood glucose (SMBG) and urine testing forketones if hyperglycemic
■Teach S&S and management of hyperglycemia, hypoglycemia, and medadministration
■Explain need for medical alert ID
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