The major sources of the glucose that circulates in the blood are through the

absorption of ingested food in the gastrointestinal tract and formation of glucose

by the liver from food substances.

Diabetes mellitus is a group of metabolic diseases that occurs

with increased levels of glucose in the blood.

Diabetes mellitus most often results in defects in insulin secretion,

insulin action, or even both.

Classification

The classification system of diabetes mellitus is unique because research

findings suggest many differences among individuals within each category, and
patients can even move from one category to another, except for patients with
type 1 diabetes.

Diabetes has major classifications that include type 1

diabetes, type 2 diabetes, gestational diabetes, and diabetes
mellitus associated with other conditions.

The two types of diabetes mellitus are differentiated based on their

causative factors, clinical course, and management.

Pathophysiology

Diabetes Mellitus has different courses of pathophysiology because of it has

several types.
Islet of Langerhans

1. Insulin is secreted by beta cells in the pancreas and it is an anabolic

hormone.

2. When we consume food, insulin moves glucose from blood

to muscle, liver, and fat cells as insulin level increases.

3. The functions of insulin include the transport and metabolism of

glucose for energy, stimulation of storage of glucose in
the liver and muscle, serves as the signal of the liverto stop releasing
glucose, enhancement of the storage of dietary fat in adipose tissue,
and acceleration of the transport of amino acid into cells.

4. Insulin and glucagon maintain a constant level of glucose in the

blood by stimulating the release of glucose from the liver.

Type 2 Diabetes Mellitus

 Pa
thophysiology of Diabetes Mellitus Type 2

Type 2 diabetes mellitus has major problems of insulin

resistance and impaired insulin secretion.

Insulin could not bind with the special receptors so insulin becomes
less effective at stimulating glucose uptake and at regulating the
glucose release.

There must be increased amounts of insulin to maintain glucose level

at a normal or slightly elevated level.

However, there is enough insulin to prevent the breakdown of fats and

production of ketones.

Uncontrolled type 2 diabetes could lead to hyperglycemic,

hyperosmolar nonketotic syndrome.
 The usual symptoms that the patient may feel are polyuria, polydipsia,
polyphagia, fatigue, irritability, poorly healing skin wounds, vaginal
infections, or blurred vision.

Epidemiology

Diabetes mellitus is now one of the most common disease all over the world.
Here are some quick facts and numbers on diabetes mellitus.

More than 23 million people in the United States have diabetes, yet
almost one-third are undiagnosed.

By 2030, the number of cases is expected to increase more than 30

million.

Diabetes is especially prevalent in the elderly; 50% of people older

than 65 years old have some degree of glucose intolerance.

People who are 65 years and older account for 40% of people with
diabetes.

African-Americans and members of other racial and ethnic groups are

more likely to develop diabetes.

In the United States, diabetes is the leading cause of non-traumatic

amputations, blindness in working-age adults, and end-stage renal
disease.

Diabetes is the third leading cause of death from disease.

Costs related to diabetes are estimated to be almost $174 billion

annually.

Causes
The exact cause of diabetes mellitus is actually unknown, yet there are factors
that contribute to the development of the disease.

Type 2 Diabetes Mellitus

Weight. Excessive weight or obesity is one of the factors that

contribute to type 2 DM because it causes insulin resistance.

Inactivity. Lack of exercise and a sedentary lifestyle can also cause

insulin resistance and impaired insulin secretion.

Clinical Manifestations

Clinical manifestations depend on the level of the patients hyperglycemia.

Polyuria or increased urination. Polyuria occurs because the

kidneys remove excess sugar from the blood, resulting in a
higher urine production.

Polydipsia or increased thirst. Polydipsia is present because the

body loses more water as polyuria happens, triggering an increase in
the patients thirst.

Polyphagia or increased appetite. Although the patient may

consume a lot of food but glucose could not enter the cells because of
insulin resistance or lack of insulin production.

Fatigue and weakness. The body does not receive enough energy
from the food that the patient is ingesting.

Sudden vision changes.The body pulls away fluid from the eye in an
attempt to compensate the loss of fluid in the blood, resulting in
trouble in focusing the vision.
Symptoms of Diabetes Mellitus.

Tingling or numbness in hands or feet. Tingling and numbness

occur due to a decrease in glucose in the cells.

Dry skin. Because of polyuria, the skin becomes dehydrated.

Skin lesions or wounds that are slow to heal. Instead of entering

the cells, glucose crowds inside blood vessels, hindering the passage of
white blood cells which are needed for wound healing.

Recurrent infections. Due to the high concentration of glucose,

bacteria thrives easily.

Prevention
Appropriate management of lifestyle can effectively prevent the development of
diabetes mellitus.

Standard lifestyle recommendations, metformin, and placebo are given

to people who are at high risk for type 2 diabetes.

The 16-lesson curriculum of the intensive program of lifestyle

modificationsfocused on weight reduction of greater than 7% of initial
body weight and physical activity of moderate intensity.

It also included behavior modification strategies that can help

patients achieve their weight reduction goals and participate in
exercise.

Complications

If diabetes mellitus is left untreated, several complications may arise from the
disease.

Hypoglycemia. Hypoglycemia occurs when the blood glucose falls

to less than 50 to 60 mg/dL because of too much insulin or oral
hypoglycemic agents, too little food, or excessive physical activity.

Diabetic Ketoacidosis. DKA is caused by an absence or markedly

inadequate amounts of insulin and has three major features of
hyperglycemia, dehydration and electrolyte loss, and acidosis.

Hyperglycemic Hyperosmolar Nonketotic Syndrome. HHNS is a

serious condition in which hyperosmolarity and hyperglycemia
predominate with alteration in the sense of awareness.

Assessment and Diagnostic Findings

Hypoglycemia may occur suddenly in a patient considered hyperglycemic
because their blood glucose levels may fall rapidly to 120 mg/dL or even less.

Serum glucose: Increased 2001000 mg/dL or more.

Serum acetone (ketones): Strongly positive.

Fatty acids: Lipids, triglycerides, and cholesterol level elevated.

Serum osmolality: Elevated but usually less than 330 mOsm/L.

Glucagon: Elevated level is associated with conditions that produce

(1) actual hypoglycemia, (2) relative lack of glucose (e.g.,
trauma, infection), or (3) lack of insulin. Therefore, glucagon may be
elevated with severe DKA despite hyperglycemia.

Glycosylated hemoglobin (HbA1C): Evaluates glucose control during

past 812 wk with the previous 2 wk most heavily weighted. Useful in
differentiating inadequate control versus incident-related DKA (e.g.,
current upper respiratory infection [URI]). A result greater than 8%
represents an average blood glucose of 200 mg/dL and signals a need
for changes in treatment.

Serum insulin: May be decreased/absent (type 1) or normal to high

(type 2), indicating insulin insufficiency/improper utilization
(endogenous/exogenous). Insulin resistance may develop secondary to
formation of antibodies.

Electrolytes:

Sodium: May be normal, elevated, or decreased.

Potassium: Normal or falsely elevated (cellular shifts), then markedly

decreased.

Phosphorus: Frequently decreased.

 Arterial blood gases (ABGs): Usually reflects low pH and decreased
HCO3 (metabolic acidosis) with compensatory respiratory alkalosis.

CBC: Hct may be elevated (dehydration); leukocytosis suggest

hemoconcentration, response to stress or infection.

BUN: May be normal or elevated (dehydration/decreased renal

perfusion).

Serum amylase: May be elevated, indicating acute pancreatitis as

cause of DKA.

Thyroid function tests: Increased thyroid activity can increase blood

glucose and insulin needs.

Urine: Positive for glucose and ketones; specific gravity and osmolality
may be elevated.

Cultures and sensitivities: Possible UTI, respiratory or wound

infections.

Medical Management

Here are some medical interventions that are performed to manage diabetes
mellitus.

Normalize insulin activity. This is the main goal of diabetes

treatment normalization of blood glucose levels to reduce the
development of vascular and neuropathic complications.

Intensive treatment. Intensive treatment is three to four insulin

injections per day or continuous subcutaneous insulin infusion, insulin
pump therapy plus frequent blood glucose monitoring and weekly
contacts with diabetes educators.
 Exercise caution with intensive treatment. Intensive therapy must
be done with caution and must be accompanied by thorough
education of the patient and family and by responsible behavior of
patient.

Diabetes management has five components and involves constant

assessment and modification of the treatment plan by healthcare
professionals and daily adjustments in therapy by the patient.

Nutritional Management

The foundations. Nutrition, meal planning, and weight control are the
foundations of diabetes management.

Consult a professional. A registered dietitian who understands

diabetes management has the major responsibility for designing and
teaching this aspect of the therapeutic plan.

Healthcare team should have the knowledge. Nurses and other

health care members of the team must be knowledgeable about
nutritional therapy and supportive of patients who need to implement
nutritional and lifestyle changes.

Weight loss. This is the key treatment for obese patients with type 2
diabetes.

How much weight to lose? A weight loss of as small as 5% to 10%

of the total body weight may significantly improve blood glucose levels.

Other options for diabetes management. Diet education,

behavioral therapy, group support, and ongoing nutritional counselling
should be encouraged.

Meal Planning
 Criteria in meal planning. The meal plan must consider the patients
food preferences, lifestyle, usual eating times, and ethnic and cultural
background.

Managing hypoglycemia through meals. To help prevent

hypoglycemic reactions and maintain overall blood glucose control,
there should be consistency in the approximate time intervals between
meals with the addition of snacks as needed.

Assessment is still necessary. The patients diet history should be

thoroughly reviewed to identify his or her eating habits and lifestyle.

Educate the patient. Health education should include the importance

of consistent eating habits, the relationship of food and insulin, and the
provision of an individualized meal plan.

The nurses role. The nurse plays an important role in communicating

pertinent information to the dietitian and reinforcing the
patients for better understanding.

Other Dietary Concerns

Alcohol consumption. Patients with diabetes do not need to give up

alcoholic beverages entirely, but they must be aware of the potential
adverse of alcohol specific to diabetes.

If a patient with diabetes consumes alcohol on an empty stomach,

there is an increased likelihood of hypoglycemia.

Reducing hypoglycemia. The patient must be cautioned to consume

food along with alcohol, however, carbohydrate consumed with alcohol
may raise blood glucose.
 How much alcohol intake? Moderate intake is considered to be one
alcoholic beverage per day for women and two alcoholic beverages per
day for men.

Artificial sweeteners. Use of artificial sweeteners is acceptable, and

there are two types of sweeteners: nutritive and nonnutritive.

Types of sweeteners. Nutritive sweeteners include all of which

provides calories in amounts similar to sucrose while nonnutritive have
minimal or no calories.

Exercise. Exercise lowers blood glucose levels by increasing the

uptake of glucose by body muscles and by improving insulin utilization.

A person with diabetes should exercise at the same time and for the
same amount each day or regularly.

A slow, gradual increase in the exercise period is encouraged.

Using a Continuous Glucose Monitoring System

A continuous glucose monitoring system is inserted

subcutaneously in the abdomen and connected to the device worn on a
belt.

This can be used to determine whether treatment is adequate over a

24-hour period.

Blood glucose readings are analyzed after 72 hours when the data has
been downloaded from the device.

Testing for Glycated Hemoglobin

 Glycated hemoglobin or glycosylated hemoglobin, HgbA1C, or A1C
reflects the average blood glucose levels over a period of
approximately 2 to 3 months.

The longer the amount of glucose in the blood remains above normal,
the more glucose binds to hemoglobin and the higher the glycated
hemoglobin becomes.

Normal values typically range from 4% to 6% and indicate consistently

near-normal blood glucose concentrations.

Pharmacologic Therapy

Exogenous insulin. In type 1 diabetes, exogenous insulin must be

administered for life because the body loses the ability to produce
insulin.

Insulin in type 2 diabetes. In type 2 diabetes, insulin may be

necessary on a long-term basis to control glucose levels if meal
planning and oral agents are ineffective.

Self-Monitoring Blood Glucose (SMBG). This is the cornerstone of

insulin therapy because accurate monitoring is essential.

Human insulin. Human insulin preparations have a shorter duration

of actionbecause the presence of animal proteins triggers an immune
response that results in the binding of animal insulin.

Rapid-acting insulin. Rapid-acting insulins produce a more rapid

effect that is of shorter duration than regular insulin.
 Short-acting insulin. Short-acting insulins or regular insulin should
be administered 20-30 minutes before a meal, either alone or in
combination with a longer-acting insulin.

Intermediate-acting insulin. Intermediate-acting insulins or NPH or

Lente insulin appear white and cloudy and should be
administered with food around the time of the onset and peak of
these insulins.

The rapid-acting and short-acting insulins are expected to cover the

increase in blood glucose levels after meals; immediately after the
injection.

Intermediate-acting insulins are expected to cover subsequent meals,

and long-acting insulins provide a relatively constant level of insulin
and act as a basal insulin.

Approaches to insulin therapy. There are two general approaches to

insulin therapy: conventional and intensive.

Conventional regimen. Conventional regimen is a simplified

regimen wherein the patient should not vary meal patterns and
activity levels.

Intensive regimen. Intensive regimen uses a more complex

insulin regimen to achieve as much control over blood glucose levels
as is safe and practical.

A more complex insulin regimen allows the patient more flexibility to

change the insulin doses from day to day in accordance with changes
in eating and activity patterns.

Methods of insulin delivery. Methods of insulin delivery include

traditional subcutaneous injections, insulin pens, jet injectors, and
insulin pumps.
 Insulin pens use small prefilled insulin cartridges that are loaded into
a pen-like holder.

Insulin is delivered by dialing in a dose or pushing a button for every

1- or 2-unit increment administered.

Jet injectors deliver insulin through the skin under pressure in an

extremely fine stream.

Insulin pumps involve continuous subcutaneous insulin infusion with

the use of small, externally worn devices that closely mimic the
function of the pancreas.

Oral antidiabetic agents may be effective for patients who have type
2 diabetes that cannot be treated by MNT and exercise alone.

Oral antidiabetic agents. Oral antidiabetic agents include

sulfonylureas, biguanides, alpha-glucosidase inhibitors,
thiazolidinediones, and dipeptidyl-peptidase-4.

Half of all the patients who used oral antidiabetic agents eventually
require insulin, and this is called secondary failure.

Primary failure occurs when the blood glucose level remains high 1
month after initial medication use.

Nursing Management

Nurses should provide accurate and up-to-date information about the patients
condition so that the healthcare team can come up with appropriate
interventions and management.

Nursing Assessment

The nurse should assess the following for patients with Diabetes Mellitus:
 Assess the patients history. To determine if there is presence of
diabetes, assessment of history of symptoms related to the diagnosis
of diabetes, results of blood glucose monitoring, adherence to
prescribed dietary, pharmacologic, and exercise regimen, the patients
lifestyle, cultural, psychosocial, and economic factors, and effects of
diabetes on functional status should be performed.

Assess physical condition. Assess the patients blood pressure while

sitting and standing to detect orthostatic changes.

Assess the body mass index and visual acuity of the patient.

Perform examination of foot, skin, nervous system and mouth.

Laboratory examinations. HgbA1C, fasting blood glucose, lipid

profile, microalbuminuria test, serum creatinine level, urinalysis, and
ECG must be requested and performed.

Diagnoses

The following are diagnoses observed from a patient with diabetes mellitus.

Risk for unstable blood glucose level related to insulin resistance,

impaired insulin secretion, and destruction of beta cells.

Risk for infection related to delayed healing of open wounds.

Deficient knowledge related to unfamiliarity with information, lack of

recall, or misinterpretation.

Risk for disturbed sensory perception related to endogenous

chemical alterations.

Impaired skin integrity related to delayed wound healing.

 Ineffective peripheral tissue perfusion related to too much glucose
in the bloodstream

Planning and Goals

Main article: 13+ Diabetes Mellitus Nursing Care Plans

Achievement of goals is necessary to evaluate the effectiveness of the therapy.

Acknowledge factors that lead to unstable blood glucose.

Maintain glucose in satisfactory range.

Verbalize plan for modifying factors to prevent or minimize shifts in

glucose levels.

Achieve timely wound healing.

Identify interventions to prevent or reduce Risk for Infection.

Regain or maintain the usual level of cognition.

Homeostasis achieved.

Causative/precipitating factors corrected/controlled.

Complications prevented/minimized.

Disease process/prognosis, self-care needs, and therapeutic regimen

understood.

Plan in place to meet needs after discharge.

Nursing Priorities

1. Restore fluid/electrolyte and acid-base balance.

 2. Correct/reverse metabolic abnormalities.

3. Identify/assist with management of underlying cause/disease process.

4. Prevent complications.

5. Provide information about disease process/prognosis, self-care, and

treatment needs.

Nursing Interventions

The healthcare team must establish cooperation in implementing the following

interventions.

Educate about home glucose monitoring. Discuss glucose

monitoring at home with the patient according to individual parameters
to identify and manage glucose variations.

Review factors in glucose instability. Review clients common

situations that contribute to glucose instability because there are
multiple factors that can play a role at any time like missing meals,
infection, or other illnesses.

Encourage client to read labels. The client must choose foods

described as having a low glycemic index, higher fiber, and low-fat
content.

Discuss how clients antidiabetic medications work. Educate

client on the functions of his or her medications because there are
combinations of drugs that work in different ways with different blood
glucose control and side effects.

Check viability of insulin. Emphasize the importance of

checking expiration dates of medications, inspecting insulin for
 cloudiness if it is normally clear, and monitoring proper storage and
preparation because these affect insulin absorbability.

Review type of insulin used. Note the type of insulin to be

administered together with the method of delivery and time of
administration. This affects timing of effects and provides clues to
potential timing of glucose instability.

Check injection sites periodically. Insulin absorption can vary day

to day in healthy sites and is less absorbable in lipohypertrophic
tissues.

Evaluation

To check if the regimen or the interventions are effective, evaluation must be

done afterward.

Evaluate clients knowledge on factors that lead to an unstable blood

glucose level.

Evaluate the clients level of blood glucose.

Verbalized achievement of modifying factors that can prevent or

minimize shifts in glucose level.

Achieved timely wound healing.

Identified interventions that can prevent or reduce risk for infection.

Evaluate maintenance of the usual level of cognition.

Discharge and Home Care Guidelines

The responsibility of the healthcare team members does not end when the
patient is discharged. The following are guidelines that should be discussed
before the patient is discharged from the hospital.
 Patient empowerment is the focus of diabetes education.

Patient education should address behavior change, self-efficacy, and

health beliefs.

Address any underlying factors that may affect diabetic control.

Simplify the treatment regimen if it is difficult for the patient to follow.

Adjust the treatment regimen to meet patient requests.

Establish as specific plan or contract with the patient with simple,

measurable goals.

Provide positive reinforcement of self-care behaviors performed instead

of focusing on behaviors that were neglected.

Encourage the patient to pursue life goals and interests, and

discourage an undue focus on diabetes.

Educate client on wound care, insulin preparation, and glucose

monitoring.

Instruct client to comply with the appointment with the healthcare

provider at least twice a year for ongoing evaluation and routine
nutrition updates.

Remind the patient to participate in recommended health promotion

activities and age-appropriate health screenings.

Encourage participation in support groups with patients who have had

diabetes for many years as well for those who are newly diagnosed.