Review Notes for Diabetes Mellitus

Description

 Diabetes mellitus is a disorder characterized by insufficient production

of insulin in the pancreas or when there is a resistance or deficiency of
available insulin resulting in hyperglycemia.
 It is characterized by disturbances in carbohydrate, protein, and fat
metabolism.
 Sustained hyperglycemia has been shown to affect almost all tissues in
the body and is associated with significant complications of multiple organ
systems, including the eyes, nerves, kidneys, and blood vessels.
Types

 Type 1 diabetes mellitus or, formerly called insulin-dependent diabetes

mellitus, typically occurs in younger people with the exact cause is
unknown. Type 1 diabetes may result from an autoimmune process
triggered by a virus 
 Type 2 diabetes mellitus, formerly called non-insulin dependent diabetes
mellitus, is characterized by defects in insulin release and use, and insulin
resistance. Commonly occurs in patients with obesity and those with
genetic susceptibility to DM. 
 Gestational diabetes mellitus is characterized by glucose intolerance of
any degree that occurs during pregnancy. 
Pathophysiology

 Type 1 diabetes mellitus: 

o There is a destruction of the islet cells in the pancreas causing
insufficient insulin and excess glucagon. 
o Glucose accumulates in the serum causing hyperglycemia. 

o Blood being delivered in the kidneys has high glucose

concentration causing osmotic diuresis and glycosuria. 
o Osmotic diuresis causes water loss, resulting in polydipsia. 
 o Lack of insulin makes the body unable to use carbohydrates
primarily and instead uses fats and proteins for energy
production, resulting in ketosis and weight loss. 
o Polyphagia and fatigue result from the break down of nutritional
stores. 
 Type 2 diabetes mellitus: 
o Insulin resistance occurs in diabetes mellitus, wherein there is a
decrease in tissue sensitivity to insulin. 
o In normal conditions, insulin binds to special receptors on the
cell surfaces and initiates reactions involved in glucose
metabolism. However, in type 2 diabetes, these intracellular
reactions are diminished, making insulin less effective at
stimulating glucose uptake by the tissues and at regulating
glucose release by the liver. 
o If the beta cells cannot keep up with the increased demand for
insulin, the glucose level rises and type 2 diabetes develops. 
 Gestational diabetes mellitus: 
o Hyperglycemia develops in pregnancy because of the secretion
of placental hormones, which causes insulin resistance. 
o Gestational diabetes is related to the anti-insulin effects of
progesterone, cortisol, and human placenta lactogen, which
increase the amount of insulin needed to maintain glycemic
control.
Complications

 Hypoglycemia is when the blood the glucose falls to less than 50 to 60

mg/dL and is linked to excessive use of hypoglycemic agents, decreased
food intake, increased physical activity, excessive alcohol consumption, or
renal failure. It often occurs before meals, especially if meals are delayed
or snacks are omitted. It can occur on type 1 or type 2 diabetes. 
 Diabetic ketoacidosis (DKA) is caused by an absence or severe
inadequacy of insulin. This deficit in available insulin results in disorders in
the metabolism of carbohydrate, protein, and fat. DKA is usually
associated with incorrect or failure to take insulin as prescribed and stress
and is occurring in clients with type 1 diabetes. 
  Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) is the
combination of severe hyperglycemia and hyperosmolarity with little or no
acidosis. The insulin level in HHNS is too low to prevent hyperglycemia but
is high enough to prevent fat breakdown. HHNS occurs in older clients (50
to 70 years old)  with type 2 diabetes and is associated with stress or
ingestion of certain drugs. 
 Microangiopathy, or diabetic microvascular disease, is characterized
by capillary basement membrane thickening most prominently in the
retina and glomerulus. 
 Diabetic retinopathy is the deterioration of the small blood vessels that
nourish the retina causing visual impairment. 
 Nephropathy is a renal dysfunction caused by microvascular changes in
the kidney secondary to diabetes mellitus. 
 Diabetic neuropathy refers to a group of diseases that affect all types of
nerves characterized by paresthesias or decreased sensation. Peripheral
neuropathy and autonomic neuropathy are two of the most common
types of neuropathy found in diabetes. 
 Increased susceptibility to infections results from an impaired ability of
granulocytes to respond to infectious agents. 
Clinical Manifestations

 Diabetes mellitus: 
o Polyuria (increased urination), polydipsia (increased thirst), and
polyphagia (increased appetite) are the classic symptoms of
diabetes mellitus, also known as the “3 P’s of DM”. 
o Fatigue and weakness
o Weight loss

o Sudden vision changes

o Tingling or numbness in hands or feet

o Dry skin
o Skin lesions or wounds that are slow to heal

o Recurrent infections (urinary, skin, vulva)

 Diabetic Ketoacidosis (DKA)
 o Dehydration
o Tachycardia

o Kussmaul’s respirations
o Nausea and vomiting

o Abdominal pain
o Acetone breath (fruity odor)

o Decreased level of consciousness

o Orthostatic hypotension
 Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
o Dehydration (dry mucous membranes, poor skin turgor)

o Decreased level of consciousness (altered sensorium, seizures,

hemiparesis)
o Tachycardia
o Hypotension
 Hypoglycemia
o Mild hypoglycemia: stimulation of the sympathetic nervous
system. 
 Sweating
 Cool, moist skin, or pallor
 Tremors
 Tachycardia
 Palpitation
 Nervousness
 Hunger
o Moderate hypoglycemia: decreased glucose levels for
the brain cells.
 Impaired CNS function
 Inability to concentrate
 Lightheadedness
  Headache
 Confusion
 Memory lapses
 Double vision
 Drowsiness
o Severe hypoglycemia: severe impairment of the CNS.
 Disoriented behavior
 Seizures
 Difficulty arousing from sleep
 Loss of consciousness
Laboratory and Diagnostics

 Diabetes mellitus
o Fasting blood glucose level above 140 mg/dL or postprandial
(after meals) blood glucose levels above 200 mg/dl measured on
more than one occasion is diagnostic. 
o Glycosylated hemoglobin (HgbA1C) shows an elevated blood
glucose level. 
 Diabetic ketoacidosis (DKA)
o Blood glucose levels between 300 and 8900 mg/dL
o Ketoacidosis is reflected in low serum bicarbonate (0 to 15
mEq/L) and low pH values. 
o Accumulation of ketone bodies is reflected in blood and urine
ketone measurements. 
o Sodium and potassium concentrations may vary depending on
the degree of dehydration. Increased levels of creatinine, blood
urea nitrogen, and hematocrit go along with dehydration. 
o Arterial blood gas indicate metabolic acidosis
 HHNS
o Serum blood glucose higher than 700 mg/dL
o Serum blood osmolality is higher than 350 mOsm/kg
 o Urine specimen reveals the absence of ketosis
o Serum electrolyte levels show hypernatremia and hypokalemia. 
 Hypoglycemia
o Serum blood glucose level is less than 70 mg/dL
Medical Management

 The main goal of treatment is to normalize insulin activity and blood

glucose levels to reduce the development of complications. 
 There are five components of management for diabetes: nutrition,
exercise, monitoring, pharmacologic therapy, and education. 
 Insulin is the primary treatment for type 1 diabetes. 
 Weight reduction is the primary treatment for type 2 diabetes. 
 Exercise enhances the effectiveness of insulin. 
Nursing Management

 Monitor blood glucose levels and provide teaching to the patient on how

to do so. 
 Administer medications, as prescribed: 
o Insulin for type 1 diabetes
o Hypoglycemic agents for type 2 diabetes (sulfonylureas,
thiazolidinediones, biguanides, alpha-glucosidase inhibitors)
 Self-administering insulin
o Provide information and teaching on how to self-administer
insulin. 
o On storing insulin: vials of insulin, when not in use, should be
refrigerated (extreme temperatures should also be avoided). 
Insulin vial that is currently in use can be kept at room
temperature (1 month). Cloudy insulins should be thoroughly
mixed by gently inverting the vial or rolling it between the hands
before drawing the solution. Intermediate-acting insulin showing
a frosted, whitish coating inside the bottle, should be discarded. 
o On selecting syringes: syringes should match the insulin
concentration. 
 o On mixing insulins: patients should be warned not to inject one
type of insulin into the bottle containing a different type of
insulin. Patients with difficulty mixing insulins may use premixed
insulin. 
o Selecting and rotating injection sites: the abdomen, upper
arms, thighs, and hips are the four main sites for insulin
injection. Rotation of injection sites is recommended to prevent
lipodystrophy which may cause a decrease in the absorption of
insulin. Encourage the patient to use all available injection sites
within one area rather than randomly rotating sites from area to
area. 
o Inserting the needle: insulin should be injected into the
subcutaneous tissue, the incorrect technique may affect the rate
of absorption. 
 Nurse teaching on diabetes
o Assess readiness to learn and include the patient’s family in
developing a diabetic teaching plan. 
o Prevention of complications

o Dietary and lifestyle changes

o Proper self-care (especially foot care)

o Administration and management of insulin

o Use of hypoglycemic medications
 Management of  DKA. 
o Treatment goal is to prevent dehydration, electrolyte loss, and
acidosis. 
o Normal saline (0.9%) is infused at a high rate to replace fluid loss.
Hypotonic solution (0.45% NS) may be used for hypertension or
hypernatremia. 
o Administer regular insulin, as ordered.
o Monitor serum glucose levels as insulin is administered. 

o Monitor potassium levels, because potassium shifts affect the

heart. 
o Monitor respirations as respiratory distress can occur. 
 o Assess vital signs, intake and output, and monitor ketone levels. 
 Management of HHNS. 
o Assess vital signs, fluid status, and laboratory values. Fluid status
and urine output are closely monitored because of the risk for
renal failure secondary to severe dehydration. 
o Because clients are usually older, monitor for heart failure and
cardiac arrhythmias.
 Management of Hypoglycemia. 
o Monitor blood glucose levels. 
o Administer glucose (oral glucose, I.V. glucose, or glucagon). 

o Advise client to carry simple sugar at all times to prevent case of

hypoglycemia.