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Diabetes Mellitus

A group of metabolic diseases characterized by elevated levels of glucose in the blood resulting from defects in
insulin secretion, insulin action, insulin receptors or any combination of conditions.
A chronic disorder of impaired glucose metabolism, protein and fat metabolism
BASIC PATHOLOGY : Insulin problem (deficiency or impaired action)
Insulin is a hormone secreted by the BETA cells of the pancreas
Stimulus of insulin- HYPERGLYCEMIA
Action of insulin: it promotes entry of Glucose into the body cells by binding to the insulin receptor in the cell
membrane
Insulin Metabolic Functions:
1. Transports and metabolizes GLUCOSE
2. Promotes GLYCOGENESIS
3. Promotes GLYCOLYSIS
4. Enhances LIPOGENESIS
5. Accelerates PROTEIN SYNTHESIS
RISK FACTORS for Diabetes Mellitus
4. Age of more than 45
5. Previously unidentified IFG/IGT
6. Hypertension
RISK FACTORS for Diabetes Mellitus
7. Hyperlipidemia
8. History of Gestational Diabetes Mellitus
CLASSIFICATION OF DM
1. Type 1 DM
Insulin dependent Diabetes Mellitus
2. Type 2 DM
Non-insulin dependent Diabetes Mellitus
3. Gestational DM
Diabetes Mellitus diagnosed during pregnancy
4. DM associated with other conditions or syndromes

CLASSIFICATION OF DM
1. Type 1 DM
Insulin dependent Diabetes Mellitus
2. Type 2 DM
Non-insulin dependent Diabetes Mellitus
3. Gestational DM
Diabetes Mellitus diagnosed during pregnancy
4. DM associated with other conditions or syndromes

Other types of DM
1. Impaired Glucose Tolerance
2. Impaired Fasting Glucose
3. Pre-diabetes
TYPE 1- Diabetes Mellitus
This type of DM is characterized by the destruction of the pancreatic beta cells
Etiology:
1. Genetic susceptibility- HLA DR3 and DR4
2. Autoimmune response
3. Toxins, unidentified viruses and environmental factors
PATHOPHYSIOLOGY
Destruction of BETA cells decreased insulin production uncontrolled glucose production by the liver
hyperglycemia signs and symptoms

CLASSIC Ps
Polyuria
Polydipsia
Polyphagia

TYPE 2- Diabetes Mellitus
A type of DM characterized by insulin resistance and impaired insulin production
Etiology:
1. Unknown
2. Probably genetic and obesity

PATHOPHYSIOLOGY
Decreased insulin production diminished insulin action hyperglycemia signs and symptoms
BUT (+) insulin in small amount prevent breakdown of fats DKA is unusual

GESTATIONAL Diabetes Mellitus
Any degree of glucose intolerance with its onset during pregnancy
Usually detected between 24-28
th
week gestation
Blood glucose returns to normal after delivery of the infant
NEVER administer ORAL HYPOGLYCEMIC AGENTS to PREGNANT MOTHERS!

ASSESSMENT FINDINGS
1. Classic 3 Ps
2. Fatigue
3. Body weakness
4. Visual changes
5. Slow wound healing
6. Recurrent skin and mucus membrane infections

DIAGNOSTIC TESTS
1. FBS- > 126
2. RBS- >200
3. OGTT- > 200
4. HgbA1- for monitoring!!
5. Urine glucose
6. Urine ketones
DIAGNOSTIC CRITERIA
1. FBS equal to or greater than 126 mg/dL (7.0mmol/L)
(Normal 8 hour FBS- 80-109 mg/dL)
2. OGTT value 1 and 2 hours post-prandial equal to or greater than 200 mg/dL
Normal OGTT 1 and 2 hours post-prandial- is140 mg/dL
3. RBS of equal to or greater than 200 mg/dL PLUS the 3 Ps

NURSING MANAGEMENT OF DM
The main goal is to NORMALIZE insulin activity and blood glucose level by:
1. Nutritional modification
2. Regular Exercise
3. Regular Glucose Monitoring
4. Drug therapy
5. Client Education
NUTRITIONAL MANAGEMENT
1.Review the patients diet history to identify eating habits and lifestyle
2. Coordinate with the dietician in meal planning for weight loss
3. Plan for the caloric intake distributed as follows- CHO 50-60%; Fats 20-30%; and Proteins 10-20%
4. Advise moderation in alcohol intake
5. Using artificial sweeteners is acceptable
EXERCISE MANAGEMENT
1. Teach that exercise can lower the blood glucose level
2. Diabetics must first control the glucose level before initiating exercise programs.
3. Offer extra food /calories before engaging in exercise
4. Offer snacks at the end of the exercise period if patient is on insulin treatment.
5. Advise that exercise should be done at the same time every day, preferably when blood glucose levels
are at their peak
6. Regular exercise, not sporadic exercise, should be encouraged.
7. For most patient, WALKING is the safe and beneficial form of exercise

Glucose Self Monitoring
Self-monitoring of blood glucose (SMBG) enables the patient to adjust the treatment regimen to obtain
optimal glucose control
Most common method involves obtaining a drop of capillary blood applied to a test strip.
The usual recommended frequency is TWO-FOUR times a day.

When is it done?
At the peak action time of the medication to evaluate the need for adjustments.
To evaluate BASAL insulin test before meals
To titrate bolus or regular and lispro test 2 hours after meals.
To evaluate the glucose level of those taking ORAL hypoglycemics test before and two hours after
meals.
Testing the glycosylated hemoglobin (HbA1c)
This glycosylated hemoglobin refers to the blood test that reflects the average blood glucose over a
period of TWO to THREE months.
Normal value is 4 to 6 %
No patient preparation is needed for this testing
Done to monitor therapy Urine testing for glucose
Urine testing for glucose
Benedicts test
Urine testing for ketones
This is performed whenever TYPE 1 DM have glucosuria or persistent elevation of blood glucose, during
illness, and in gestational diabetes


DRUG THERAPY and MANAGEMENT
Usually, this type of management is employed if diet modification and exercise cannot control the blood glucose
level.
Because the patient with TYPE 1 DM cannot produce insulin, exogenous insulin must be administered for life.
TYPE 2 DM may have decreased insulin production, ORAL agents that stimulate insulin production are usually
employed.
PHARMACOLOGIC INSULIN
This may be grouped into several categories according to:
1. Source- Human, pig, or cow
2. Onset of action- Rapid-acting, short-acting, intermediate-acting, long-acting and very long acting
This may be grouped into several categories according to:
3. Pure or mixed concentration
4. Manufacturer of drug
GENERALITIES
1. Human insulin preparations have a shorter duration of action than animal source
2. Animal sources of insulin have animal proteins that may trigger allergic reaction and they may stimulate antibody
production that may bind the insulin, slowing the action
3. ONLY Regular insulin can be used INTRAVENOUSLY!
4. Insulin are measured in INTERNATIONAL UNITS or iu
5. There is a specified insulin injection calibrated in units
RAPID ACTING INSULIN
Lispro (Humalog) and Insulin Aspart (Novolog)
Produces a more rapid effect and with a shorter duration than any other insulin preparation
ONSET- 5-15 minutes
PEAK- 1 hour
DURATION- 3 hours
Instruct patient to eat within 5 to 15 minutes after injection
REGULAR INSULIN
Also called Short-acting insulin
R
Usually Clear solution administered 30 minutes before a meal
ONSET- 30 minutes to 1 hour
PEAK- 2 to 3 hours
DURATION- 4 to 6 hours
INTERMEDIATE ACTING INSULIN
Called NPH or LENTE
Appears white and cloudy
ONSET- 2-4 hours
PEAK- 4 to 6-12 hours
DURATION- 16-20 hours
LONG- ACTING INSULIN
UltraLENTE
Referred to as peakless insulin
ONSET- 6-8 hours
PEAK- 12-16 hours
DURATION- 20-30 hours