Diabetes Mellitus

Diabetes mellitus is a group of metabolic disorders characterized

by elevated levels of blood glucose (hyperglycemia) resulting

from defects in insulin secretion, insulin action, or both. Three

major acute complications of diabetes related to short-term

imbalances in blood glucose levels are hypoglycemia, diabetic

ketoacidosis (DKA), and hyperglycemic hyperosmolar nonketotic

syndrome (HHNS). Long-term hyperglycemia may contribute

to chronic microvascular complications (kidney and eye

disease) and neuropathic complications. Diabetes is also associated

with an increased occurrence of macrovascular diseases,

including coronary artery disease (myocardial infarction), cerebrovascular

disease (stroke), and peripheral vascular disease.

Types of Diabetes

Type 1 (Formerly Insulin-Dependent Diabetes Mellitus)

• About 5% to 10% of patients with diabetes have type 1 diabetes.

It is characterized by destruction of the pancreatic

beta-cells due to genetic, immunologic, and possibly environmental

(eg, viral) factors. Insulin injections are needed

to control the blood glucose levels.

• Type 1 diabetes has a sudden onset, usually before the age

of 30 years.
Type 2 (Formerly Non–Insulin-Dependent

Diabetes Mellitus)

• About 90% to 95% of patients with diabetes have type 2 diabetes.

It results from a decreased sensitivity to insulin (insulin

resistance) or from a decreased amount of insulin production.

• Type 2 diabetes is first treated with diet and exercise, and

then with oral hypoglycemic agents as needed.

• Type 2 diabetes occurs most frequently in patients older

than 30 years and in patients with obesity.

Gestational Diabetes Mellitus

• Gestational diabetes is characterized by any degree of glucose

intolerance with onset during pregnancy (second or

third trimester).

• Risks for gestational diabetes include marked obesity, a personal

history of gestational diabetes, glycosuria, or a strong

family history of diabetes. High-risk ethnic groups include

Hispanic Americans, Native Americans, Asian Americans,

African Americans, and Pacific Islanders. It increases their

risk for hypertensive disorders of pregnancy.

Clinical Manifestations

• Polyuria, polydipsia, and polyphagia.

• Fatigue and weakness, sudden vision changes, tingling or

numbness in hands or feet, dry skin, skin lesions or wounds

that are slow to heal, and recurrent infections.

• Onset of type 1 diabetes may be associated with sudden

weight loss or nausea, vomiting, or stomach pains.

• Type 2 diabetes results from a slow (over years), progressive

glucose intolerance and results in long-term complications if

diabetes goes undetected for many years (eg, eye disease,

peripheral neuropathy, peripheral vascular disease). Complications

may have developed before the actual diagnosis is made.

• Signs and symptoms of DKA include abdominal pain, nausea,

vomiting, hyperventilation, and a fruity breath odor.

Untreated DKA may result in altered level of consciousness,

coma, and death.

Assessment and Diagnostic Methods

• High blood glucose levels: fasting plasma glucose levels 126

mg/dL or more, or random plasma glucose or 2-hour postload

glucose levels more than 200 mg/dL

• Evaluation for complications

Prevention

For patients who are obese (especially those with type 2 diabetes),

weight loss is the key to treatment and the major preventive

factor for the development of diabetes.

Complications of Diabetes
Complications associated with diabetes are classified as acute

and chronic. Acute complications occur from short-term

imbalances in blood glucose and include the following:

• Hypoglycemia

•DKA

• HHNS

Chronic complications generally occur 10 to 15 years after

the onset of diabetes mellitus. The complications include the

following:

• Macrovascular (large vessel) disease: affects coronary,

peripheral vascular, and cerebral vascular circulations

• Microvascular (small vessel) disease: affects the eyes

(retinopathy) and kidneys (nephropathy); control blood glucose

levels to delay or avoid onset of both microvascular and

macrovascular complications

• Neuropathic disease: affects sensory motor and autonomic

nerves and contributes to such problems as impotence and

foot ulcers

Gerontologic Considerations

Because the incidence of elevated blood glucose levels

increases with advancing age, elderly adults should be advised

that physical activity that is consistent and realistic is beneficial

to those with diabetes. Advantages of exercise include a

decrease in hyperglycemia, a general sense of well-being, and

better use of ingested calories, resulting in weight reduction.

Consider physical impairment from other chronic diseases

when planning an exercise regimen for elderly patients with

diabetes.

Medical Management

The main goal of treatment is to normalize insulin activity

and blood glucose levels to reduce the development of vascular

and neuropathic complications. The therapeutic goal

within each type of diabetes is to achieve normal blood glucose

levels (euglycemia) without hypoglycemia and without

seriously disrupting the patient’s usual activities. There are five

components of management for diabetes: nutrition, exercise,

monitoring, pharmacologic therapy, and education.

• Primary treatment of type 1 diabetes is insulin.

• Primary treatment of type 2 diabetes is weight reduction.

• Exercise is important in enhancing the effectiveness of insulin.

• Use oral hypoglycemic agents if diet and exercise are not

successful in controlling blood glucose levels. Insulin injections

may be used in acute situations.

• Because treatment varies throughout the course because of

changes in lifestyle and physical and emotional status as well

as advances in therapy, continuously assess and modify treatment

plan as well as daily adjustments in therapy. Education

is needed for both patient and family.

Nutritional Management

• Goals are to achieve and maintain blood glucose and blood

pressure levels in the normal range (or as close to normal as

safely possible) and a lipid and lipoprotein profile that

reduces the risk for vascular disease; to prevent, or at least

slow, the rate of development of chronic complications; to

address individual nutrition needs; and to maintain the

pleasure of eating by only limiting food choices when indicated

by scientific evidence.

• Meal plan should consider the patient’s food preferences,

lifestyle, usual eating times, and ethnic and cultural background.

• For patients who require insulin to help control blood glucose

levels, consistency is required in maintaining calories

and carbohydrates consumed at different meals.

• Initial education addresses the importance of consistent eating

habits, the relationship of food and insulin, and the provision

of an individualized meal plan. In-depth follow-up

education then focuses on management skills, such as eating

at restaurants; reading food labels; and adjusting the

meal plan for exercise, illness, and special occasions.

Caloric Requirements
• Determine basic caloric requirements, taking into consideration

age, gender, body weight, and height and factoring in

degree of activity.

258 Diabetes Mellitus

• Long-term weight reduction can be achieved (1 to 2 lb loss

per week) by reducing basic caloric intake by 500 to 1,000

cal from calculated basic caloric requirements.

• The American Diabetes and American Dietetic Associations

recommend that for all levels of caloric intake, 50%

to 60% of calories be derived from carbohydrates, 20% to

30% from fat, and the remaining 10% to 20% from protein.

Using food combinations to lower the glycemic response

(glycemic index) can be useful. Carbohydrate counting and

the food guide pyramid can be useful tools.

Nursing Management

Nursing management of patients with diabetes can involve

treatment of a wide variety of physiologic disorders, depending

on the patient’s health status and whether the patient is

newly diagnosed or seeking care for an unrelated health problem.

Because all patients with diabetes must master the concepts

and skills necessary for long-term management and

avoidance of potential complications of diabetes, a solid educational

foundation is necessary for competent self-care and is

an ongoing focus of nursing care.

Providing Patient Education

Diabetes mellitus is a chronic illness that requires a lifetime

of special self-management behaviors. Nurses play a vital role

in identifying patients with diabetes, assessing self-care skills,

providing basic education, reinforcing the teaching provided

by the specialist, and referring patients for follow-up care after

discharge.

Developing a Diabetic Teaching Plan

• Determine how to organize and prioritize the vast amount

of information that must be taught to patients with diabetes.

Many hospitals and outpatient diabetes centers have devised

written guidelines, care plans, and documentation forms

that may be used to document and evaluate teaching.

• The American Association of Diabetes Educators recommends

organizing education using the following seven tips

for managing diabetes: healthy eating, being active, monitoring,

taking medication, problem solving, healthy coping,

and reducing risks.

• Another general approach is to organize information