Diabetes Mellitus (DM)

Bhaumika SharmaLecturer College of NursingChitwan Medical College

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INSULIN SECRETION AND FUNCTION

• Insulin is a hormone secreted by the beta cells of the islet of Langerhans in the pancreas.

• Increased secretion or a bolus of insulin, released after a meal, helps maintain euglycemia.

• Through an internal feedback mechanism (pancreas and liver), circulating blood glucose levels are maintained at a normal range of 60 to 110 mg/dL.

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Contd.

• Insulin is essential for the utilization of glucose for cellular metabolism as well as for the proper metabolism of protein and fat.

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Contd. • Carbohydrate metabolism: insulin affects the

conversion of glucose into glycogen for storage in the liver and skeletal muscles, and allows for the immediate release and utilization of glucose by the cells.

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• Protein metabolism: amino acid conversion occurs in the presence of insulin to replace muscle tissue or to provide needed glucose (gluconeogenesis).

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• Fat metabolism: storage of fat in adipose tissue and conversion of fatty acids from excess glucose occurs only in the presence of insulin.

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Diabetic Mellitus (DM)

• Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.

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Epidemiology

• Diabetes mellitus affects about 17 million people, 5.9 million of whom are undiagnosed.

• In the United States, approximately 800,000 new cases of diabetes are diagnosed yearly

• Diabetes is especially prevalent in the elderly, with up to 50% of people older than 65 suffering some degree of glucose intolerance.

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• In the United States, diabetes is the leading cause of nontraumatic amputations, blindness among working-age adults, and end-stage renal disease

• Diabetes is the third leading cause of death by disease, primarily because of the high rate of cardiovascular disease (myocardial infarction, stroke, and peripheral vascular disease) among people with diabetes.

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Classification of DM

Type 1 Diabetes Mellitus: • Formerly known as insulin dependent diabetes

mellitus and juvenile diabetes mellitus.• Five to 10% of all diabetic patients have type 1. • Most commonly seen in patients under age 30

but can be seen in older adults.

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• Etiology: autoimmunity, viral, and certain histocompatibility antigens as well as a genetic component.

• Clinical Features: usual presentation is rapid with classic symptoms of polydipsia, polyphagia, polyuria and weight loss.

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Type 2 Diabetes Mellitus• Formerly known as noninsulin dependent diabetes

mellitus or adult onset diabetes mellitus. • Approximately 90% of diabetic patients have type

2. • It is caused by a combination of insulin resistance

and relative insulin deficiency• Found primarily in adults over age 30; however,

may be seen in younger adults and adolescents who are overweight.

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• Etiology: strong hereditary component commonly associated with obesity.

• Clinical Features: usual presentation is slow and typically insidious with symptoms of fatigue, weight gain, poor wound healing, and recurrent infection.

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Gestational Diabetes Mellitus (GDM)

• GDM is defined as carbohydrate intolerance occurring during pregnancy.

• Occurs in approximately 4% of pregnancies and usually disappears after delivery.

• Women with GDM are at higher risk for diabetes at a later date.

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• GDM is associated with increased risk of fetal morbidity.

• Screening for GDM for all pregnant women should occur between the 24th and 28th weeks of gestation.

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Diabetes Associated with Other Conditions

• Certain drugs can decrease insulin activity resulting in hyperglycemia: corticosteroids, thiazide diuretics, estrogen, phenytoin.

• Disease states affecting the pancreas or insulin receptors: pancreatitis, cancer of the pancreas, Cushing's disease or syndrome, acromegaly, pheochromocytoma, muscular dystrophy, Huntington's chorea.

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Etiology and Risk Factors

Type I

• Identical twins 25% to 50% inherited• Siblings 6% and offspring 5% risk• Virus appear to trigger autoimmune process:

islet cell antibody, autoimmunity

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Type II

• Identical twins: 58% to 50% inherited• Obesity• Prevalence of coronary artery disease

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PHYSIOLOGY AND PATHOPHYSIOLOGY OF DIABETES• Type I DM– 5 stagesStage I: genetic predispositionStage 2: environmental triggerStage 3: active autoimmunity Stage 4: progressive beta cell destructionStage 5: overt diabetes mellitus

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• Blood Glucose• Fasting blood sugar (FBS): drawn after at least

an 8-hour fast, to evaluate circulating amounts of glucose

• Postprandial test (PP): drawn usually 2 hours after a well-balanced meal, to evaluate glucose metabolism; and random glucose, drawn at any time, nonfasting.

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• People with gene marker DR3 or DR4 HLA indicate risk for type I DM

• Environmental triggers: coincidence of various viral diseases

• Slow, progressive insult to beta cells and endogenous insulin molecules

• Acute illness and stress: leads to hyperglycemia, when acute illness resolves, client my revert to compensated state of variable duration, honeymoon period.

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Type II• 1st: Beta cells chronically exposed to high

blood levels of glucose become progressively less efficient when responding to further glucose elevations, phenomenon termed as desensitization, is reversible by normalizing glucose levels

•

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• 2nd: Resistance to biologic activity of insulin in both the liver and peripheral tissues, state known as insulin resistance

• In type II DM there is decreased sensitivity to glucose levels, which results in continued hepatic glucose production, even with high plasma glucose level

• Also inability of muscle and fat tissues to increase glucose uptake aids

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Clinical Manifestations • Hyperglycemia • 3 P’s– Polyuria (increased urination)– Polydipsia (increased thirst)– polyphagia (increased appetite)

• Weight loss, fatigue• Blurred vision• Poor wound healing• Recurrent infections, particularly of the skin08/04/23 25

Diagnostic Evaluation

• Diabetes can be diagnosed in any of the following ways (and should be confirmed on a different day by any of these tests):– FBS of ≥126 mg/dL – Random blood glucose of ≥200 mg/dL with classic

symptoms (polyuria, polydipsia, polyphagia, weight loss)

– OGTT greater than or equal to 200 mg/dL on the 2-hour sample

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Contd.

• Tests for glucose control over time are glycated hemoglobin and fructosamine assay.

• These tests are not used for diagnosis.

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Management

Diet• Dietary control with caloric restriction of

carbohydrates and saturated fats to maintain ideal body weight.

• The goal of meal planning is to control blood glucose and lipid levels.

• Weight reduction is a primary treatment for type 2 diabetes.

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Contd.

Exercise• Regularly scheduled, moderate exercise

performed for at least 30 minutes most days of the week promotes the utilization of carbohydrates, assists with weight control, enhances the action of insulin, and improves cardiovascular fitness.

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Medication• Oral antidiabetic agents for patients with type

2 diabetes who do not achieve glucose control with diet and exercise only.

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Oral hypoglycemic Drugs

Second-Generation Sulfonylureas

Glyburide (Micronase, DiaBeta)

1.25-20 mg in single or divided dose with meals

Glyburide, micronized (Glynase)

0.75-12 mg in single or divided dose

Glipizide (Glucotrol) 2.5-40 mg in single dose or divided dose with meals

Glipizide (Glucotrol XL)

5-20 mg in single dose before breakfast

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Contd.

Agents Dose BiguanidesMetformin (Glucophage) 500-2,550 mg in 2-3 divided

doses with mealsMetformin (Glucophage XR) 500-2,000 mg daily with evening

mealAlpha-Glucosidase InhibitorsAcarbose (Precose) 150-300 mg in 3 doses with

meals; if < 60 kg, maximum dose 50 mg tid

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Contd.

Agents Dose Meglitinide AnalogueRepaglinide (Prandin) 0.5-16 mg in 2-4 divided doses within

30 minutes of starting meal; if meal is skipped, do not take dose

Amino Acid DerivativeNateglinide (Starlix) 120-360 mg in 3 divided doses within

30 minutes of starting meal; if meal is skipped, do not take dose

ThiazolidinedionesRosiglitazone (Avandia) 4-8 mg in a single dose or 2 divided

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Contd.

Agents Dose Combination AgentsGlyburide/metformin (Glucovance)

Up to 20/2,000 mg/day in single dose or divided doses

Glipizide/metformin (Metaglip)

Up to 20/2,000 mg/day in single dose or divided doses

Rosiglitazone/metformin (Avandamet)

Up to 8/2,000 mg/day in divided doses

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Sites of Action of Oral Anti-diabetic DrugsSites of Action of Oral Anti-diabetic Drugs

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Insulin Therapy

INSULIN ONSET PEAK DURATIONImmediate-acting(lispro, aspart)

0.25 hour 0.5-1 hour 5 hours

Short-acting(regular, semilente)

0.5-1 hour 2-4 hours 5-7 hours

Intermediate-acting

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INSULIN ONSET PEAK DURATIONLong-acting(ultralente) 4-6 hours 10-30 hours 24-36 hours(insulin glargine)

1 hour none 24+1 hours

Mixed(Regular 30%, NPH 70%)

0.5 hour 2-12 hours 24 hours

(Regular 50%, NPH 50%)

0.5 hour 3-5 hours 24 hours

(Lispro 25%, NPH 75%)

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Five components of Diabetic Management

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Patient Education: Self Insulin Injection

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Areas for Insulin InjectionAreas for Insulin Injection

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Microfilaments for Testing of Sensation

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Disposable Filament for Patient

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Insulin Pump

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DIAGNOSTIC TESTS

Blood Glucose• Fasting blood sugar (FBS): drawn after at least

an 8-hour fast, to evaluate circulating amounts of glucose

• Postprandial test (PP): drawn usually 2 hours after a well-balanced meal, to evaluate glucose metabolism; and random glucose, drawn at any time, nonfasting.

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Nursing and Patient Care Considerations• Advise patient to refrain from smoking before

the glucose sampling because this affects the test results.

• For postprandial test, advise patient that no food should be eaten during the 2-hour interval.

• For random blood glucose, note the time and content of the last meal.

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• Interpret blood values as diagnostic for diabetes mellitus as follows:– FBS greater than or equal to 126 mg/dL on two

occasions– Random blood sugar ≥200 mg/dL and presence of

classic symptoms of diabetes (polyuria, polydipsia, polyphagia, and weight loss)

• Fasting blood glucose result of ≥100 mg/dL demands close follow-up and repeat monitoring.

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Oral Glucose Tolerance Test (OGTT)

• OGTT evaluates insulin response to glucose loading. FBS is obtained before the ingestion of a 50- to 200-g glucose load (usual amount is 75 g), and blood samples are drawn at ½, 1, 2, and 3 hours (may be 4- or 5-hour sampling).

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Nursing and Patient Care Considerations• Advice patient to use usual diet and exercise

pattern must be followed for 3 days before OGTT.

• During OGTT, the patient must refrain from smoking and remain seated.

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Contd.

• Oral contraceptives, salicylates, diuretics, phenytoin, and nicotinic acid can impair results and may be withheld before testing based on the advice of the health care provider.

• Diagnostic for diabetes mellitus if 2-hour value is 200 mg/dL or greater.

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Glycated Hemoglobin (Glycohemoglobin, HbA1c)

HbA1c measures glycemic control over a 60- to 120-day period by measuring the irreversible reaction of glucose to hemoglobin through freely permeable erythrocytes during their 120-day lifecycle.

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Contd.

Nursing and Patient Care Considerations• No prior preparation, such as fasting or

withholding insulin, is necessary.• Test results can be affected by red blood cell

disorders (eg, thalassemia, sickle cell anemia), room temperature, ionic charges, and ambient blood glucose values.

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C-Peptide Assay (Connecting Peptide Assay)

• Cleaved from the proinsulin molecule during its conversion to insulin, C-peptide acts as a marker for endogenous insulin production.

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Contd.

Nursing and Patient Care Considerations• Test can be performed after an overnight fast

or after stimulation with Sustacal, I.V. glucose or 1 mg of glucagon subcutaneously.

• Absence of C-peptide indicates no beta cell function, reflecting possible type 1 diabetes.

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Testing for Ketones

• When there is almost no effective insulin available, the body starts to break down stored fat for energy.

• Ketone bodies are byproducts of this fat breakdown, and they accumulate in the blood and urine.

• Ketones (or ketone bodies) in the urine signal that control of type 1 diabetes is deteriorating, and the risk of DKA is high.

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Contd.

• Urine testing is the most common method used for self-testing of ketone bodies by patients.

• Urine ketone testing should be performed whenever patients with type 1 diabetes have glucosuria or persistently elevated blood glucose levels (more than 240 mg/dL or 13.2 mmol/L for two testing periods in a row) and during illness, in pregnancy with pre-existing diabetes, and in gestational diabetes.

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General Health

The American Diabetes Association (2003) recommends the following goals of treatment.

• Glycemic control

–HbA1c < 7%

–Preprandial glucose 90 to 130 mg/dL–Peak postprandial glucose < 180 mg/dL

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• BP < 130/80 mm Hg• Lipid control

–Low-density lipoprotein < 100 mg/dL–High-density lipoprotein > 40 mg/dL–Triglycerides < 150 mg/dL

• Microalbumin (spot urine) < 30 mcg/mg creatinine

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Complications of Diabetes Mellitus

Acute1. Hypoglycemia occurs as a result of an

imbalance in food, activity, and insulin/oral antidiabetic agent.

2. Diabetic ketoacidosis (DKA) occurs primarily in type 1 diabetes during times of severe insulin deficiency or illness, producing severe hyperglycemia, ketonuria, dehydration, and acidosis.

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3. Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) affects patients with type 2 diabetes, causing severe dehydration, hyperglycemia, hyperosmolarity, and stupor.

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Chronic1.Macroangiopathy– Cerebrovascular Disease– Coronary Artery Disease (CAD)– Peripheral Vascular Disease

2.Microangiopathy– Retinopathy– Nephropathy– Peripheral Neuropathy

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3. Autonomic Neuropathy– Gastroparesis– Impotence/Sexual Dysfunction– Orthostatic Hypotension

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• In type 1 diabetes, chronic complications usually appear about 10 years after the initial diagnosis.

• The prevalence of microvascular complications (retinopathy, nephropathy) and neuropathy is higher in type 1 diabetes.

• Because of its insidious onset, chronic complications can appear at any point in type 2 diabetes.

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• Macrovascular complications: in particular cardiovascular disease, occurring in type 1 and type 2 diabetes are the leading cause of morbidity and mortality among persons with diabetes.

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• Nursing Assessment• Obtain a history of current problems, family

history, and general health history.– Has the patient experienced polyuria, polydipsia,

polyphagia, and any other symptoms?– Number of years since diagnosis of diabetes– Family members diagnosed with diabetes, their

subsequent treatment, and complications

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Contd.

• Perform a review of systems and physical– General: recent weight loss or gain, increased

fatigue, tiredness, anxiety– Skin: skin lesions, infections, dehydration,

evidence of poor wound healing– Eyes: changes in vision floaters, halos, blurred

vision, dry or burning eyes, cataracts, glaucoma

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– Mouth: gingivitis, periodontal disease– Cardiovascular: orthostatic hypotension, cold

extremities, weak pedal pulses, leg claudication– GI: diarrhea, constipation, early satiety, bloating,

increased flatulence, hunger or thirst

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– Genitourinary (GU): increased urination, nocturia, impotence, vaginal discharge

– Neurologic: numbness and tingling of the extremities, decreased pain and temperature perception, changes in gait and balance

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Nursing Diagnoses

• Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures

• Fear related to insulin injection• Risk for Injury (hypoglycemia) related to

effects of insulin, inability to eat

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• Activity Intolerance related to poor glucose control

• Deficient Knowledge related to use of oral hypoglycemic agents

• Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities

• Ineffective Coping related to chronic disease and complex self-care regimen

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Nursing Interventions

Improving Nutrition• Assess current timing and content of meals.• Advise patient on the importance of an

individualized meal plan.• Reducing intake of carbohydrates may benefit

some patients

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• Set a goal of a 10% (of patient's actual body weight) weight loss over several months in reducing blood sugar and other parameters.

• Assist patient to identify problems and their solutions that may have an impact on dietary adherence

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Contd.

• Emphasize that lifestyle changes should be maintained.

• Explain the importance of exercise in maintaining/reducing body weight.

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Contd.

• Teaching About Insulin• Assist patient to reduce fear of injection by

encouraging verbalization regarding insulin injection, sense of empathy, and identifying supportive coping techniques.

• Demonstrate and explain thoroughly the procedure for insulin self-injection.

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Contd.

• Help patient to master technique by taking a step-by-step approach.– Allow patient time to handle insulin and syringe to

become familiar with the equipment.– Teach self-injection first to alleviate fear of pain

from injection.– Instruct patient in filling syringe when he or she

expresses confidence in self-injection procedure.

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• Review dosage and time of injections in relation to meals, activity, and bedtime.Preventing Injury Secondary to Hypoglycemia

• Closely monitor blood glucose levels to detect hypoglycemia.

• Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid hypoglycemia.

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Contd.

• Assess patient for the signs and symptoms of hypoglycemia.– Adrenergic (early symptoms) sweating, tremor, pallor,

tachycardia, palpitations, nervousness from the release of adrenalin when blood glucose falls rapidly

– Neurologic (later symptoms) light-headedness, headache, confusion, irritability, slurred speech, lack of coordination, staggering gait from depression of central nervous system as glucose level progressively falls

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Contd.

• Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates.– Half cup (4 oz) juice, 1 cup skim milk, three glucose

tablets, four sugar cubes, five to six pieces of hard candy may be taken orally.

– Nutrition bar specially designed for diabetics supplies glucose from sucrose, starch, and protein sources with some fat to delay gastric emptying and prolong effect; may prevent relapse.

– Used after hypoglycemia treated with fact-acting carbohydrate.

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Contd.

– Glucagon 1 mg (subcutaneously or I.M.) is given if the patient cannot ingest a sugar treatment. Family member or staff must administer injection.

– I.V. bolus of 50 mL of 50% dextrose solution can be given if the patient fails to respond to glucagon within 15 minutes.

• Encourage patient to carry a portable treatment for hypoglycemia at all times.

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Contd.

• Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin.

• Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia.

• Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency.

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Caring for Patients With Diabetes Mellitus

Improving Activity Tolerance• Advise patient to assess blood glucose level

before and after strenuous exercise.• Instruct patient to plan exercises on a regular

basis each day.• Encourage patient to eat a carbohydrate

snack before exercising to avoid hypoglycemia.

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Contd.

• Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia.

• Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present.

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Contd.

• Patient should contact health care provider if levels remain elevated.

• Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised.

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Contd.

• Providing Information About Oral Antidiabetic Agents

• Encourage active participation of the patient and family in the educational process.

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Contd.

• Teach the action, use, and adverse effects of oral antidiabetic agents.– Sulfonylurea compounds promote the increased

secretion of insulin – Potential adverse reactions include hypoglycemia,

photosensitivity, GI upset, allergic reaction, reaction to alcohol, cholestatic jaundice, and blood dyscrasias.

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Contd.

– Metformin (Glucophage), a biguanide compound, appears to diminish insulin resistance.

– Metformin must be used cautiously in renal insufficiency, conditions that may cause dehydration, and hepatic impairment.

– Potential adverse reactions include GI disturbances, metallic taste, and lactic acidosis (rare).

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– Alpha-glucosidase inhibitors (acarbose [Precose] and miglitol [Glyset]) delay the digestion and absorption of complex carbohydrates (including sucrose or table sugar) into simple sugars, such as glucose and fructose, thereby lowering postprandial and fasting glucose levels.

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– Thiazolidinedione derivatives (rosiglitazone [Avandia] and pioglitazone [Actos]) primarily decrease resistance to insulin in skeletal muscle and adipose tissue without increasing insulin secretion.

– Secondarily, they reduce hepatic glucose production. – Ovulation may occur in anovulatory premenopausal

women. – Adverse reactions include edema, weight gain,

anemia, and elevation in serum transaminases.

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• Meglitinide analogues (repaglinide [Prandin]) and amino acid derivatives (nateglinide [Starlix]) stimulate pancreatic release of insulin in response to a meal.

• They should not be taken when a meal is skipped or missed.

• They should be used cautiously in patients with renal and hepatic dysfunction, and may cause hypoglycemia.

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Contd.

Maintaining Skin Integrity• Assess feet and legs for skin temperature,

sensation, soft tissue injuries, corns, calluses, dryness, deep tendon reflex– Use a monofilament to test sensation of the feet

and detect early signs of peripheral neuropathy.

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Contd.

• Maintain skin integrity by protecting feet from breakdown.– Use heel protectors, special mattresses, foot

cradles for patients on bed rest.– Avoid applying drying agents to skin (eg, alcohol).– Apply skin moisturizers to maintain suppleness

and prevent cracking and fissures.

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Contd.

• Advise the patient to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral blood flow.

• Help patient to establish behavior modification techniques to eliminate smoking in the hospital and to continue them at home for smoking-cessation program.

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Improving Coping Strategies• Discuss with the patient the perceived effect of

diabetes on lifestyle, finances, family life, occupation.• Explore previous coping strategies and skills that have

had positive effects.• Encourage patient and family participation in diabetes

self-care regimen to foster confidence.• Identify available support groups to assist in lifestyle

adaptation.• Assist family in providing emotional support.

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