Diabetes Mellitus

 On completion of this lecture, the learner will be able

to:
 Differentiate between type 1 and type 2 diabetes.
 Describe etiologic factors associated with diabetes.
 Relate the clinical manifestations of diabetes to the

associated path physiologic alterations.

 Identify the diagnostic, treatment ,nursing processes

and complications.
 Explain the dietary modifications used for management

of people with diabetes

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 The Pancreas
 The pancreas, located in the upper abdomen,

has endocrine as well as exocrine functions .

 The exocrine functions include secretion of

pancreatic enzymes into the gastrointestinal

tract through the pancreatic duct.
 The endocrine functions include secretion of

insulin, glucagon, and somatostatin directly

into the bloodstream
 endocrine part of the pancreas, are
collections of cells embedded in the
pancreatic tissue.
 They are composed of alpha, beta, and

delta cells.
 The hormone produced by the beta cells is

called insulin; the alpha cells secrete

glucagon and the delta cells secrete
somatostatin
 Insulin is an anabolic, or storage, hormone.
 Diabetes mellitus (DM) is a group of diseases
characterized by high levels of blood glucose
resulting from defects in insulin production, insulin
action, or both.

 The term diabetes mellitus describes a metabolic

disorder of multiple aetiology characterized by
chronic hyperglycaemia with disturbances of
carbohydrate, fat and protein metabolism resulting
from defects in insulin secretion, insulin action, or
both.

 The effects of diabetes mellitus include long–term

damage, dysfunction and failure of various organs.
 Diabetes mellitus may present with characteristic
symptoms such as thirst, polyuria, blurring of vision,
and weight loss.

 In its most severe forms, ketoacidosis or a non–

ketotic hyperosmolar state may develop and lead to
stupor, coma and, in absence of effective treatment,
death.

 Often symptoms are not severe, or may be absent,

and consequently hyperglycaemia sufficient to cause
pathological and functional changes may be present
for a long time before the diagnosis is made.
 Type 1 Diabetes Mellitus
 Type 2 Diabetes Mellitus
 Gestational Diabetes
 Other types:
Secondary Diabetes Mellitus
 Pancreatic diseases
 Endocrinological diseases
 Drugs: thiazide diuretics, steroid
 Was previously called insulin-dependent diabetes
mellitus (IDDM) or juvenile-onset diabetes.
 Type 1 diabetes develops when the body’s
immune system destroys pancreatic beta cells,
the only cells in the body that make the hormone
insulin that regulates blood glucose.
 This form of diabetes usually strikes children and
young adults, although disease onset can occur at
any age.
 Type 1 diabetes may account for 5% to 10% of all
diagnosed cases of diabetes.
 Risk factors for type 1 diabetes may include
autoimmune, genetic, and environmental factors.
 Was previously called non-insulin-dependent
diabetes mellitus (NIDDM) or adult-onset
diabetes.
 Type 2 diabetes may account for about 90% to
95% of all diagnosed cases of diabetes.
 It usually begins as insulin resistance, a
disorder in which the cells do not use insulin
properly. As the need for insulin rises, the
pancreas gradually loses its ability to produce
insulin.
 Type 2 diabetes is associated with older age,
obesity, family history of diabetes, history of
gestational diabetes, impaired glucose
metabolism, physical inactivity, and race.
 Type 2 diabetes is increasingly being
diagnosed in children and adolescents.
Risk Factors for Diabetes
Type 1 Type 2
 Under 30  Older age
 Genetics  Overweight
 Autoimmune  Hypertension
 Environment  Abnormal lipid levels
 Viral  Genetics

infection  Race/ethnicity
 History of gestational

diabetes
 History of vascular disease
 Inactivity
 Type 1 IDDM; common signs& symptoms include ;
1.Weight loss :abnormal metabolism of fat and protein
 2.Weakness or fatigability
 3.Polyuria : presence of increased glucose levels in the

urine.
 4.Polyphagia: (excessive hunger)

Increase appetite

:
5. Polydipsia (excessive thirst),
Due to the hydration caused by polyuria .
6.Keto acidosis: Smell of acetone and subsequent respiratory a
lkalosis
7.Hyperglycemia: Due to inability of glucose to enter the cells.
8.glucoseuria: Due to increase in plasma glucose
9 .Nocturia : nighttime urination
( Increase urine during night)
 1.Being excessively thirsty
 2.Passing more urine
 3.Always feeling fatiuge
 4.Having cut that heal slowly
 5.Itching skin infections
 6.Blurred vision
 7.Gradually putting on weight

8.Mood swings 9.Headaches

10.Feeling dizzy 11.Leg cramps
History & Sign and symptoms
 Oral Glucose Tolerance Test
Another test to diagnose diabetes is the oral glucose
tolerance test (OGTT).
 An OGTT measures blood glucose at intervals after the

patient drinks a concentrated carbohydrate drink.

Diabetes is diagnosed when the blood glucose le vel is
200 mg/dL or greater after 2 hours. A result between
140 and 199 mg/dL at 2 hours leads to a diagnosis of
impaired glucose tolerance and prediabetes.
is the term given when there is either of the
following:
oral glucose tolerance test is higher than
normal but not high enough for a diagnosis of
diabetes (7.8–11.0 mmol/L)
fasting plasma glucose is higher than normal
(6.1–6.9 mmol/L) but less than the level
confirming the presence of diabetes.
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 Glycohemoglobin
The glycohemoglobin test (also called
glycosylated
hemoglobin, or HbA1c [hemoglobin A1C]) is
used to gather baseline data and to monitor
the progress of diabetes control.In 2009,
the ADA also changed its guidelines to
include the HbA1c as a diagnostic test for
diabetes.
Glucose in the blood attaches to
hemoglobin in the red blood cells, which live
about 3 months
 Not needed to confirm DM
 Complete blood count
 Urea and electrolytes
 Liver function test
 Lipid profile
 Urine general
Management of
Diabetes
Mellitus
 The major components of the treatment of
diabetes are:
 Diet is a basic part of management in every
case. Treatment cannot be effective unless
adequate attention is given to ensuring
appropriate nutrition.

 Dietary treatment should aim at:

◦ ensuring weight control
◦ providing nutritional requirements
◦ allowing good glycaemic control with blood
glucose levels as close to normal as possible
◦ correcting any associated blood lipid
abnormalities
The following principles are recommended as dietary
guidelines for people with diabetes:

 Dietary fat should provide 25-35% of total intake of calories

but saturated fat intake should not exceed 10% of total
energy. Cholesterol consumption should be restricted and
limited to 300 mg or less daily.

 Protein intake can range between 10-15% total energy (0.8-1

g/kg of desirable body weight). Requirements increase for
children and during pregnancy. Protein should be derived from
both animal and vegetable sources.

 Carbohydrates provide 50-60% of total caloric content of the

diet. Carbohydrates should be complex and high in fibre.

 Excessive salt intake is to be avoided. It should be particularly

restricted in people with hypertension and those with
nephropathy.
 Physical activity promotes weight reduction and
improves insulin sensitivity, thus lowering blood
glucose levels.
 Together with dietary treatment, a programme
of regular physical activity and exercise should
be considered for each person. Such a
programme must be tailored to the individual’s
health status and fitness.
 People should, however, be educated about the
potential risk of hypoglycaemia and how to
avoid it.
 If life style changes and healthy diet are
not satisfactorily controlling the diabetes
in 4 to 6 weeks, drugs is to be added
 DRUGS: anti hyperglycemia
 Biguanide (metformin): (decreases

gluconeogenesis and increases peripheral

utilisation of glucose)
 Sulfonylureas (gliclazide,) (act mainly by

augmenting insulin secretion)

 Treatment complication monitoring
1. Annula eye examination
2. Annula micro albuminuria
3. Feet examination
4. Bp monitoring
5. Lipid profile
 Insulin types :
1 -The rapid acting insulin types:
insulin aspart, insulin glulisine and
insulin lispro

2 – Short or fast acting:

soluble insulin (s/c, onset of action 30
to 60 min, peak action between 2
and 4 hours)
3- Intermediate acting: isophane
insulin
4 - long acting: protamine zinc insulin,
insulin detemir, and insulin glargine
5 -Mixed insulin
6 -Insulin pump see continuous
subcutaneous insulin infusion
 7- islet cell transplantation an
investigational procedure in which purified
islet cells from cadaver donors are injected
into the portal vein of the liver, with the goal
of having these cells secrete insulin and cure
type 1 diabetes
Location Of Insulin
Njection

35
 Patients should be educated to practice self-
care. This allows the patient to assume
responsibility and control of his / her own
diabetes management. Self-care should
include:

◦ Blood glucose monitoring

◦ Body weight monitoring
◦ Foot-care
◦ Personal hygiene
◦ Healthy lifestyle/diet or physical activity
◦ Identify targets for control
◦ Stopping smoking
 Exercise
 Monitoring BP
 Emotion Condition
 Education about safety precaution
 The patient with diabetes
 Assessment :

Nursing assessment of the PT with diabetes

focuses on the presence and duration of
the classical symptoms of the
hyperglycemia .
Factors that affect blood glucose :
1) Changes in dietary habits with increased
intake.
 Why physical assessment is essential?
 Because diabetes can effect every system

in the body
 Assessment incloudes ;
 1)skin :- check groin, axillae and

inframammary areaes women

 -assess any reddened lesions with sharply
 -Check elbows ,knees for anathemas
 -check insulin injection site for atrophy ,

hyperatrophy
Mouth ;-check teeth for periodontal disease
and dental caries ,check tongue
Eyes check visual acuity and use an
ophthalmoscope to assess Cataracts and
retinopathy and hemorrhages
 CVS
 Check weight, BP and pulses
 Assess signs and symptoms of cardiac

disease (dyspnea, chest pain ,irregular

heart beats
 PVS peripheral vascular system;
 Check legs and feet for any circulatory status

cool thin shiny skin thick hair loss over dorsum

of foot pulse strength ulcerations
 Kidneys assess for edema swelling renal

involvement , fluid retention , urinary tract

infection , weakness , exhaustion
 Neuromusculars ( neuropathy):-
 Check hand for atrophy and burns (assess

sensation)
 Check muscle disfunction
 Note gastrointestinal disturbances
 Check for bladder dysfunction
 Check for reproductive dysfunction , male

impotence and female sexuality problems

 Psychosocial assessment focuses on the

impact of living with diabetes as a chronic

disease, a careful assessment of the pts
 Attitude about the disease , understanding

of the treatment plan and participation in

their own care
 Based on assessment data include :-
 1- deficit in knowledge concerning methods for

maintaining normal blood glucose levels

 2- ulteration in nutrition related to dietary regulation to

combat abnormal metabolism of carbohydrates ,

proteins and fat
 3- feelings of powerlessness related to the uncertainties

of disease and development

 4- potential impairment of skin integrity secondary to
hyperglycemia and vascular problems
 5- potential for injury related to decease tactile

sensation and diminished visual activity

 6-potential sexual dysfunction in the male related to

erectile problems secondary to neuropathy

 7- potential development of long term complications

related to persistent hyperglycemia and accelerated

vascular disease
 1.Increase the knowledge of the diabetes methods
of maintaining N B educate PT about the G.
2.Improved metabolism of carbohydrates ,proteins
and fats
 .3.Ability to control the day to day management of
diabetes and its potential complications
 4.Maintenance of skin integrity.
 5.Prevention of injury.
 6.Maintenance or improvement of sexual function.
 7.Control of long -term complication of diabetes
 1- Acute
 There are three major acute complications

of diabetes hypoglycemia,
 diabetic ketoacidosis (DKA),
 and hyperglycemic hyperosmolar

nonketotic syndrome (HHNS

 Immediate treatment must be given 15 g of
a fast-acting concentrated source of
carbohydrate such as the following, given
orally:
 Three or four commercially prepared

glucose tablets
 4 to 6 oz of fruit juice or regular soda
 6 to 10 hard candies
 2 to 3 teaspoons of sugar or honey
 is aimed at correcting dehydration,
electrolyte loss, and acidosis.
 Rehydration The patient may need as much

as 6 to 10 L of IV fluid
 Initially, 0.9% sodium chloride (normal

saline) solution is administered at a rapid

rate, usually 0.5 to 1 L/hour for 2 to 3 hours
the IV solution may be changed to dextrose
5% in water (D5W) to prevent a precipitous
decline in the blood glucose level.
 Restoring Electrolytes
 Insulin administration, which enhances the movement

of potassium from the extracellular fluid into the cells

 Cautious but timely potassium replacement is vital to

avoid dysrhythmias that may occur with hypokalemia

 Frequent (every 2 to 4 hours initially) ECGs and

laboratory measurements of potassium are necessary

during the first 8 hours of treatment.
 Potassium replacement is withheld only if

hyperkalemia is present or if the patient is not urinating

 Vascular Disease
 Macrovascular Complications
 Diabetic macrovascular complications result

from changes in the medium to large blood

vessels.
Microvascular
 Retinopathy Nephropathy
 Neuropathy
 Cardiomyopathy
 include progressive development of the
specific complications of retinopathy with
potential blindness, nephropathy that may
lead to renal failure, and/or neuropathy with
risk of foot ulcers, amputation and sexual
dysfunction.
 People with diabetes are at increased risk of

cardiovascular, peripheral vascular and

cerebrovascular disease.
Vascular Disease DSF (diabetic septic foot)
Cardiomyopathy Retinopathy
Diabetic
Nephropathy
Damage to the kidney which can lead to
chronic renal failure, eventually requiring
dialysis. Diabetes mellitus is the most
common cause of adult kidney failure
worldwide in the developed world

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Thank You