DIABETIC MELLITUS (DM)

Content
Definition
Classification
Cause and risk factors
Sign and symptom
Complication
Physical examination
Diagnosis
management
 Diabetes mellitus
 Diabetes mellitus :is a group of heterogeneous disorders
characterized by elevated level of glucose in the blood
(hyperglycemia)
Diabetes mellitus : is a clinical syndrome characterized by
hyperglycemia due to absolute or relative deficiency of insulin
 Insulin: is a hormone produced by pancreases, control the level
of glucose in the blood by regulating production and storage of
glucose
Increase concentration of glucose in the blood lead to damage
blood vessels and nerves
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 Classification

There are several types of D.M.

1. Type I: Insulin dependent diabetes mellitus(IDDM)
2. Type II: Non – insulin dependent diabetes mellitus(NIDDM)
3. D.M. associated with other condition or syndrome
4. Gestational diabetes mellitus(G.D.M.)

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 Type I D.M

5-10% people with D.M. –type I

Insulin produced by pancreas but destroyed by auto immune
process
 So injection insulin is needed

Characterized by sudden onset / usually before 30 yrs

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 Type II DM

Approximately 90-95% people with D.M. type II

Result from decreased sensitivity to insulin (insulin resistance) or
decreased amount of insulin product
Rx with diet and exercise, but if glucose level persist – oral
hypoglycemic agent
Occur older than 30 yrs of age and obese

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 DM Associated with other condition or syndrome

 Previously classified as secondary diabetes

Because of underlying conditions like

 surgery
 drugs(corticosteroids, thiazides, atypical antipsychotics
 malnutrition
 illnesses (Cushing's, hyperthyroidism, recurrent pancreatitis)
 Accounts 1% to 5% of cases

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 Gestational DM

 Diabetes diagnosed during pregnancy

 Placental hormones contributes to insulin resistance(inhibit
action of insulin)
 Common between 24-28 weeks of gestation
 Goes away after birth, but increased risk of developing Type 2
DM for mother and child

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 Characteristics of Diabetes

Type 1 Type 2
 Usually under 30  Usually over 40
 Rapid onset  Gradual onset
 Normal or underweight  80% are overweight
 Little or no insulin  Most have insulin resistance
 Ketosis common  Ketosis rare
 Autoimmune plus  Metabolic insulin resistance
environmental factors syndrome
 Low familial factor  Strongly hereditary
 Treated with insulin, diet and  Diet & exercise, progressing to
exercise tablets, then insulin
Insulin secretion increase when meal is eaten and moves glucose
in to liver, muscle and fat cell for storage.
Insulin function:
 Facilitate storage of glucose in liver and muscle in the form

of glycogen
 Enhance storage of dietary fat in adipose tissue
 Accelerate transport of amino acid in to cells
 Insulin is anabolic (storage) hormone
 Insulin: is the only anabolic hormone and it has profound effect

on the metabolism of CHO, protein and fat.

 Type I DM

Characterized by destruction of the pancreatic beta cells

Factors for destruction of beta cells are:
Genetic
Immunologic
Environmental

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 The classical symptoms of type I DM

 Thirst (polydeptia)
 Polyuria
 Polyphagia
 Nocturia
 rapid weight loss

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 Type II DM

Due to insulin resistance and impaired insulin secretion

Exact mechanism is unknown but
 Genetic factors are thought to play a role in the development
of insulin resistance
 Age
 Obesity
 Family history

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 Clinical manifestations
 Thirst (polydeptia)
 Polyuria
 Polyphagia
 Nocturia
 Tiredness, fatigue, irritability, apathy,
 Recent change in weight
 Blurring of vision
 Nausea, headache
 The classical symptom of thrist, polyuria, nocturia, rapid
weight loss predominant in type I often absent in type II

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 Physical Assessment

The initial physical examination focuses on signs of any health

problems as well as developing diabetic complications.
The exam includes:
 Height, weight, and calculation of body mass index (BMI)
 Blood pressure
 Funduscopic eye exam
 Skin exam for poorly healing injuries and signs of reduced
circulation
 Foot exam, including palpation of pulses and tests of fine
sensation.
 Investigation or diagnosis

An abnormally high blood glucose level is the basic criterion for

the diabetes diagnosis.
 Fasting plasma glucose (FPG) levels > 126 mg/dL (7.0
mmol/L) or more.
 Random plasma glucose(RPG) levels exceeding 200 mg/dL
(11.1 mmol/L) on more than one occasion are diagnostic of
diabetes.
 Oral Glucose tolerance test(OGTT) is the best Diagnostic
test.

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 Prediabetes

 Is when blood glucose levels are higher than

normal but not high enough for a diagnosis of
diabetes.
 OGTT b/n 140 and 199 mg/dL after 2 hours
shows impaired glucose tolerance (IGT)
 A diagnosis of impaired fasting glucose (IFG) is
made when the fasting glucose level is between
110 and 125 mg/dL.
 A person is at increased risk for developing type
2 diabetes (many people within 10 years)
 Investigation or diagnosis…
Glucose tolerance test :
 The patient ingests high CHO(150 – 300gm) meals for three days
preceding the test after an over night fast, a blood sample is drown
 Then 75gm CHO load usually in the form of carbonated bevrage

Instructed the patient:-

 to sit quietly during the test, avoid exercise, smoking, coffee and
any other intake except H2O
 According to WHO 2 hrs after glucose ingestion, blood sample is
drawn
 2 hrs sample during 75g OGTT, >200mg/dl(11.1mmol/lt) 18
Categorization of glucose status
FBS
 Normal: FBS < 100 mg/dl
 Impaired: FBS 100-125 mg/dl
 DM: FBS≥ 126 mg/dl
RBS
 Normal: RBS <140 mg/dl
 Impaired: FBS 140 – 199 mg/dl
 DM: FBS ≥ 200 mg/dl
 DM Management
There are five components of management
1. Diet/nutritional management
2. Exercise
3. Monitoring
4. Medication/pharmacologic therapy
5. Education

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 Management cont…
Type one: insulin + healthy eating + exercise
Type two:
 Healthy eating + exercise
 Then healthy eating + exercise + tablets
 Then healthy eating + exercise + tablets + insulin
 I. Dietary management

The most important objective in dietary management is

 control of total calorie intake
 maintain reasonable body wt and control blood glucose level

Aim:-
 Abolish symptom of hyperglycemia
 Reduce overall blood glucose and minimal fluctuation
 Achieve weight reduction in obese patient to reduce insulin
resistance

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 50% to 60% of calories from carbohydrates (complex and high in
fibre)
 20-30% or less of calories from fat(but saturated fat intake should
not exceed 10% of total energy)
 10-20% of calories from protein –the use of some non animal
sources of protein help to reduce saturated fat and cholesterol intake.
 A regular pattern of meals and snacks is important to maintain a
constant daily intake of carbohydrate and protect against
hypoglycemia

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 Alcohol

 Not completely restricted

 Take moderate amount
 If excess amount –hypoglycemia
 Alcohol decrease normal physiologic reaction the body that
produce glucose (gluconeogensis), thus patient that take
alcohol empty stomach, increase likelihood of hypoglycemia
 In addition to this excessive weight gain because of high
calorie content of alcohol
 Advice to take alcohol along food
 II. exercise

 Exercise lowers blood glucose by increasing the uptake of

glucose by body muscle and improve insulin utilization
 Improve circulation and muscle tone
 To avoid hypoglycemia after exercise take/eat snack after
session

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 III. Monitoring
Self-monitoring of blood glucose
 Patients on insulin should check sugars 2-4 times per
day(usually before meals and at bedtime).
 Not on insulin, at least 2 or 3 times per week
 For all patients, testing is recommended whenever
hypoglycemia or hyperglycemia is suspected, with changes in
medications, activity, or diet, and with stress or illness.

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Urine Glucose and Ketone Monitoring
Most people have glucose in their urine when their
blood glucose is more than 180 mg/dl.
Urine should be tested for ketones during acute
illness or stress, when BGL are consistently
>240mg/dl, during pregnancy, or when symptoms of
Ketoacidosis are present.
 IV. Medication
Lower blood glucose after meals by facilitating the uptake and
utilization of glucose by muscle, fat and liver cells
During period of fasting, insulin inhibits the breakdown of stored
glucose, protein and fats
 Type I: insulin must
 Type II: used on long term basis to control glucose level, if
diet and oral hypoglycemic agent failed
 Some patient usually control by diet alone or
 Diet with oral hypoglycemic agent
 Diet with insulin during, infection, pregnancy and surgery28
 Regular insulin
 Time: Short acting
 Onset: ½-1 hour
 Peak: 2-3 hrs
 Duration: 4-6hrs
 Appearance: clear
 Indications: Usually administered 20-30min before meal, may
be taken alone or in combination with long acting insulin

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 Neutral Protamin Hagedron/NPH
 Time: Intermediate
 Onset: 3-4 hrs
 Peak: 4-12hrs
 Duration: 16-20 hrs
 Appearance: white and milk
 Indications: usually after food

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 Ultralente Insulin
 Time: Long acting
 Onset: 6-8hrs
 Peak: 12-16 hrs
 Duration: 20-30 hrs
 Indications: Used primary to control fasting glucose level

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 Insulin regimen

Vary from one injection to four injection per day

Usually combination of short acting and long acting insulin
1. Conventional regimen:
One – two injection per day
Aim :
 to avoid acute complication of diabetes
(hypoglycemia)
 Important for terminal patient or any patient

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2. Intensive regimen
Three – four injection per day
Aim:
 to achieve as much control over blood pressure level
as is safe and practical
 Twice – daily administration of S.A. and L.A. given in
combination before bread fast and evening meal is
simplest and most commonly used regimen

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 Administrating the injection

Site selection and rotation four main area:

The abdomen

Arm (posterior surface)

Thigh (anterior surface)

Hip (buttock)

 Absorption rapid in abdomen and decrease respectively

arm, thigh and hip

 Route:- subcutaneous 35
 Absorption of insulin may be influenced by:-
Site, Depth and Volume of injection

Rotate every 2 to 3 weeks:

 To prevent localized in fatty tissue.
 To promote consistency in insulin absorption
 Administer each injection ½ to 1 inch away from previous
injection
 Always use the same area at the same time of day

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 Problem of insulin

 Local allergy (redness, swelling and tenderness)

 Systemic allergy
 localized edema
 Hypoglycemia
 Wt gain

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 B. Oral ant diabetic(Oral hypoglycemic agents.)

Oral ant diabetics are Effective for type II who can not treated by diet
and exercise
1. Sulfonylureas
 Stimulate pancreas to secrete insulin
 Decrease production of glucose by liver

E.g.: Glibenclimide/Daonil/ is the most common

2. Biguandies
 Reduce intestinal absorption of glucose
 Facilitating insulin on peripheral receptors

E.g. metformin
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 Acute Complication of Diabetes mellitus

3 major acute complication of diabetes related to short term

imbalance in blood glucose
1. Hypoglycemia
2. Diabetes keteoacidosis
3. Hyperglycemic hyperosmolar non-ketotic coma

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 Hypoglycemia/ Insulin shock

Occurs when the blood glucose fails below 50 to 60mg/dl (2.7 to

3.3 mmol/lt)
Causes
 Missed, delayed or inadequate meal
 Unexpected or unusual exercise
 Alcohol
 Error in oral hypoglycemic agent or insulin dose/schedule/a
administration
 Malabsorbation
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 Symptoms

Mild hypoglycemia
 Tremor
 Tachycardia
 Palpitation
 Nervousness
 Hunger

Moderate hypoglycemia
 Headache . Numbness of lip and tongue
 Confusion . Slurred speech
 Memory lapse . Double vision
 Inability to concentrate . Drowsiness
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 Sever hypoglycemia

 Patient need assistance of another person for treatment of

hypoglycemia
 Disoriented behavior
 Seizure
 Difficulty arousing from sleep
 Loss of consciousness

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 Treatment

 10-15gm of fast acting sugar orally

 Glucose tablets
 Fruit juice
 Hard candies
 Table sugar

N.B. Simple sugar raise blood glucose level rapidly

If symptom persist more than 10-15min, after treatment, repeat
the treatment.

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 Cont.
 Avoid high carbohydrate, high calorie food such as cookies and
cakes, ice creams
The high fat contents of these food slow absorption of glucose and
the hypoglycemic symptom may not be resolved as quickly as they are
with the intake simple sugar

Patient with a severe hypoglycemia i.e.

 Unconsciousness

 Unable to swallow

 Refuse to treatment

 Glucagon's 1gm s/c, which stimulate the liver to release glucose

 In the hospital, 50% dextrose in water IV 45

 Patient education

Hypoglycemia prevented by:

 Follow regular pattern for eating
 Between meal and bed time snacks may be needed to counter
act the maximum effect
 Routine blood glucose test for adjustment
 Wear an identification bracelets or tags indicating they have
diabetes
 Instruct the family to inform if they see unusual behavior
 Carry candy on his pocket
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 Essentials of Foot Care
 Examination
 Annually for all patients
 Patients with neuropathy-visual inspection of feet at every
visit with a health care professional
 Advise patients to:
 Use lotion to prevent dryness and cracking
 Cut toenails weekly or as needed
 Always wear socks and well-fitting shoes
 Good foot hygiene
 Notify their health care provider immediately if any foot
problems occur(daily assessment)
 Diabetic Ketoacidosis /DKA/

DKA: When there is excessive a mount of ketone bodies in our body

said to be ketoacidosis
Causes
1. Decreased or missed dose of insulin
 During prescription/ insufficient dosage/

 Error by patient during dosage

2. Illness or infection
 Illness associated with insulin resistance

 Stress increase secretion of glucagon's-increase glucose production

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C/F
The hyperglycemia DKA leads to:-
 Polyuria and polydypsia
 Blurred vision, weakness, headache

 Polyuria and polydipsia

 Extreme fatigue and weakness
 Dry tongue and bucal mucosa , poor skin turgor and
hypotension
 Nausea and vomiting, abdominal pain
 Kussmaul respiration : deep and fast breathing
(hyperventilation)
 Acetone ("fruity") odour of breath
 The patient may be alert, lethargic, or comatose

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Investigation to dx DKA:-
urea and electrolyte, blood glucose
Urine analysis for ketones
Full blood count

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• Rx aim in DKA:- correction of the three main problems:
Dehydration
Electrolyte loss
Acidosis

A.Fluid replacement
Rehydration is important for maintaining tissue perfusion
Initially 0.9% normal saline is administer at high rate
Hypotonic N/S (0.45%) may be used for patient with HPN
Monitor fluid volume status (intake and out put)

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B. Electrolyte loss replacement
 Replace potassium

 Although plasma concentration of potassium may be low, normal

or even high, there is a major loss of potassium from store, further

more level of potassium drop during treatment of DKA,
 Rehydration increase urinary excretion of potassium

 Because potassium level drop during treatment of DKA,

potassium must be infuse even if the plasma concentration normal

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C. Acidosis
• Insulin: inhibit the fat breakdown, there by stopping the
building up of acids
• IV slowly
• Dextrose add when blood glucose level reach 250 to 300
mg/dl to avoid rapid drop in blood glucose

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 Nursing Management
 Monitor blood sugar and educate patient about diabetes.
 Examine feet and skin and teach patient foot care
 Educate the patient on foot protection
 Monitor vitals
 Teach the patient about insulin self-injections.
 Teach the patient about hypoglycemia and how to manage it
 Teach the patient about nutrition and the importance of
exercise
 Urge the patient not to smoke and to abstain from alcohol
 ! ! !
O U
K Y
A N
T H
 (practical)
Glucometer and
Insulin injection and preparation