Tan, Jan Beatrice Y.

BSNIII-D Group D16

1. The eight risk factors assoiated with Diabetes Mellitus are obesity, family history (genes), race/ethnicity,
age of 45 and above, previously identified impaired fasting glucose or impaired glucose tolerance, having
hypertension, HDL cholesterol level of <35mg/dL and triglyceride level of >250mg/dL, history of
gestational diabetes or delivery of baby of over 9 lbs.
As a nurse, one must educate patient about diet, planning of activities and insulin shots, other
medications and CBG monitoring. The nurse must also support the patient through
encouragement and healthy coping
2.

Current Classification Clinical Characteristics and ClinicalImplications

Type 1
-5 to 10% of all diabetes
-Previously classified as juvenile
diabetes, juvenile-onset diabetes,
ketosis-prone diabetes, brittle
diabetes, and insulin dependent
diabetes mellitus (IDDM)
 Onset any age, but usually young (<30 years)
 Usually thin at diagnosis; recent weight loss
 Etiology includes genetic, immunologic, and environmental
factors (e.g. virus)
 Often have islet cell antibodies
 Often have antibodies to insulin even before insulin treatment
 Little or no endogenous insulin
 Need insuln to preserve life
 Ketosis prone when insulin absent
 Acute complication of hyperglycemia: diabetic ketoacidosis

Type 2  Onset any age, usually over 30 years

-90 to 95% of all diabetes: obese—
80% of type 2; nonobese—20% of
type 2
-Previously classified as adult onset
diabetes, maturity-onset diabetes,
ketosis-resistant diabetes, stable
diabetes, and non-insulin-
dependent diabetes (NIDDM)
 Usually obese at diagnosis
 Causes include obesity, heredity, and environmental factors
 No islet cell antibodies
 Decrease in endogenous insulin, or increased with insulin
resistance
 Most patients can control blood glucose through weight loss if
obese
 Oral antidiabetic agents may improve blood glucose levels if
dietary modification and exercise are unsuccessful
 May need insulin on a short-term or long-term basis to prevent
hyperglycemia
 Ketosis uncommon, except in stress or infection
 Acute complication: hyperglycemic hyperosmolar nonketotic
syndrome

Diabetes Mellitus  Accompanied by conditions known or suspected to cause the

-Associated wit other conditions or diabetes: pancreatic diseases, hormonal abnormalities,
syndromes medications such as corticosteroids and estrogen-containing
-Previously classified as secondary preparations
diabetes  Depending on the ability of the pancreas to produce insulin, the
 patient may require treatments with oral antidiabetic agents or
insulin

Gestational Diabetes  Onset during pregnancy, usually in the second or third trimester
 Due to hormones secreted by the placenta, which inhibit the
action of insulin
 Above-normal risk for perinatal complications, especially
macrosomia (abnormally large babies)
 Treated with diet and, if needed, insulin to strictly maintain
normal blood glucose levels
 Occurs in about 2-5% of all pregnancies
 Glucose intolerance transitory but may recur:
- In subsequent pregnancies
- 30-40% will develop overt diabetes (usally type 2) within 10
years (especially if obese)
 Risk factors include obesity, age older than 30 years, family
history of diabetes, previous large babies (>9 lbs)
 Screening tests (glucose challenge test) should be perfomed on
all pregnant women between 24- and 28-weeks gestation
 Should be screened for diabetes periodically

Prediabetes  Previous history of hyperglycemia (eg, during pregnancy or

-Previously classified as previous
abnormality of glucose tolerance
(Prev AGT)
illness)
 Current normal glucose metabolism
 Impaired glucose tolerance or impaired fasting glucose screening
after age 40 years if tere is a family history of diabetes or if
symptomatoc
 Encourage ideal body weight, because loss of 10-15 lb may
improve glycemic control

3. Insulin is very important it transports and metabolizes glucose for energy, stimulates storage of glucose in
the liver and muscle, signals the liver to stop the release of glucose, enhances storage of dietary fat in
adipose tissue, accelerates transport of amino acids into cells and inhibits the breakdown of stored
glucose, protein and fat.

4. Insulin, being an anabolic hormone, increases when a person eats. It moves glucose from the blood into
muscle, liver and fat cells where it performs all its major activities (written above). During fasting periods
(between meals and overnight) the pancreas continuously releases a small amount of insulin (basal
insulin); another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of
Langerhans) is released when blood glucose levels decrease and stimulates the liver to release stored
glucose. The insulin and ther glucagon together maintain a constant level of glucose in the blood by
stimulating the release of glucose from the liver.
5. Insulin-dependant diabetes mellitus (IDDM) or Dm type 1 is caused by a lack of insulin secretion from the
beta cells of the pancreas which cannot synthesize enough amount of insulin hormone as required by the
body. It may be that the beta cells have been damaged by a viral infection or an autoimmune disease ( in
which the body's own immune system generates secretion of substances that attack the beta cells of the
pancreas )and so their functioning is seriously impaired.
Type I diabetes is treated with insulin which is injected using an insulin pump. Providing that the condition
is diagnosed quickly and the diabetic controls their diet and insulin injections then there is no reason why
they can’t continue life as normal.
Type II diabetes is also called non-insulin dependant diabetes mellitus (NIDDM) and is caused by
decreased sensitivity of target tissues to the metabolic effects of insulin and affects approximately 90% to
95% of people with the disease This reduced sensitivity is often referred to as insulin resistance which is
commonly secondary to obesity. Normally, insulin binds to special receptors on cell surfaces and initiates
a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are
diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating
glucose release by the liver.

6. GDM occurs among pregnant women. It is caused due to fluctuations of the hormonal level during
pregnancy. It is any degree of glucose intolerance with its onset during pregnancy. Hyperglycemia
develops during pregnancy because of the secretion of placental hormones, which causes insulin
resistance. Gestational diabetes occurs in as many as 14% of pregnant women and increases their risk for
hypertensive disorders during pregnancy.
Women who are marked obesity, has a personal history of GDM, glycosuria, or a strong family
history of diabetes should be checked for GDM. High-risk ethnic groups include Hispanic Americans,
Native Americans, Asian Americans, African Americans and Pacific Islanders.

7. The term glycemic index is used to describe how much a given food increases the blood glucose level
compared wit an equivalent amount of glucose. It utilized to avoid sharp, rapid increase in blood glucose
levels after eating. It is also used to describe how much a given food increases the blood glucose level
compared with an equivalent amount of glucose. The effects of use of the glycemic index on blood
glucose levels and on long-term patient outcomes are unclear, but it may be beneficial.

8.
 Local Allergic Reactions. A local allergic reaction (redness, swelling, tenderness, and induration or
a 2- to 4-cm wheal) may appear at the injection site 1 to 2 hours after the insulin administration.
These reactions, which usually occur during the beginning stages of therapy and disappear with
continued use of insulin, are becoming rare because of the increased use of human insulins. The
physician may prescribe an antihistamine to be take 1 hour before the injection if such a local
reaction occurs.
 Systemic Allergic Reactions. Systemic allergic reactions to insulin are rare. When they do occur,
there is an immediate local skin reaction that gradually spreads into generalized urticatia (hives).
These rare reactions are occasionally associated with generalized edema or anaphylaxis. The
treatment is desensitization, with small dose of insulin administered in gradually increasing
amounts using a desensitization kit.
 Insulin Lipodystrophy. Lipodystrophy refers to a localized reaction, in the form of either
lipoatrophy or lipohypertrophy, occurring at the site of insulin injections. Lipoatrophy is loss of
subcutaneous fat; it appears as slight dimpling or more serious pitting of subcutaneous fat. The
use of human insulin has almost eliminated this disfiguring complication.
 Resistance to Injected Insulin. Most patients have some degree of insulin resistance at one time
or another. This may occur for various reasons, the most common being obesity, which can be
 overcome by weight loss. Clinical insulin resistance has been defined as a daily insulin
requirement of 200 units or more. In most patients with diabetes wo take insulin, immune
antibodies develop and bind the insulin, thereby decreasing the insulin available for use. All
animal insulins, and human insulins to lesser degree, cause antibody production in humans.
 Morning Hyperglycemia. An elevated blood glucose level on arising in the morning is caused by
an insufficient level of insulin, which may be caused by several factors: the dawn phenomenon,
the Somogyi effect, or insulin warning.

9. Rapid-acting insulins produce a more rapid effect that is of shorter duration than regular insulin. Because
of their rapid onset, the patient should be instructed to eat no more than 5 to 15 minutes after injection.
Because of the short duration of action of these insulin analogues, patients with type 1 diabetes and some
patients with type 2 or gestational diabetes also require a long-acting insulin (basal insulin) to maintain
glucose control. Basal insulin is necessary to maintain blood glucose levels irrespective of meals. A
constant level of insulin is required at all times. Intermediate-acting insulins function as basal insulins but
may have to be split into two injections to achieve 24-hour coverage.
Administration of mixtures of rapid- or short- and intermediate- or long-acting insulins will
produce a more normal glycemia in some patients than use of a single insulin. The formulations and
particle size distributions of insulin products vary. On mixing, physicochemical changes in the mixture may
occur (either immediately or over time). As a result, the physiological response to the insulin mixture may
differ from that of the injection of the insulins separately.

Longer- acting insulin must be mixed thoroughly before drawing into the syringe. There are
varying opinions regarding which type of insulin (short- acting or rapid acting) should be drawn up first
into the syringe when they are going to be mixed. The ADA recommends that the regular insulin be drawn
up first. But we must keep in mind that the most important issue with regards to this are:
 Patients should be consistent in the technique that they use, so as not to draw up the wrong
dose in error or the wrong type of insulin.
 Patients should not inject one type of insulin into the bottle containing a different type of insulin.
Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and
alters its action.

 Patients who are well controlled on a particular mixed-insulin regimen should maintain their
standard procedure for preparing their insulin doses.
 No other medication or diluent should be mixed with any insulin product unless approved by the
prescribing physician.
 Insulin glargine should not be mixed with other forms of insulin due to the low pH of its diluent.

 Use of commercially available premixed insulins may be used if the insulin ratio is appropriate to
the patient’s insulin requirements.
 Currently available NPH and short-acting insulin formulations when mixed may be used
immediately or stored for future use.
 When rapid-acting and ultralente insulins are mixed, there is no blunting of the onset of action of
the rapid-acting insulin. A slight decrease in the absorption rate, but not the total bioavailability,
is seen when rapid-acting and protamine-stabilized insulin (NPH) are mixed. In clinical trials,
however, the postprandial blood glucose response was similar when rapid-acting insulin was
mixed with either NPH or ultralente. When rapid-acting insulin is mixed with either an
intermediate- or long-acting insulin, the mixture should be injected within 15 min before a meal.
 Mixing of short-acting and lente insulins is not recommended except for patients already
adequately controlled on such a mixture. Upon mixing, Zn 2+ present in lente insulins (e.g., lente
and ultralente) will bind with the short-acting insulin and delay its onset of action. The degree
and rate of binding varies with the ratio and species of the two insulins; binding equilibrium may
 not be reached for 24 h. If short-acting and lente mixtures are to be used, the patient should
standardize the interval between mixing and injection.
 Phosphate-buffered insulins (e.g., NPH insulin) should not be mixed with lente insulins. Zinc
phosphate may precipitate, and the longer-acting insulin will convert to a short-acting insulin to
an unpredictable extent.
 Insulin formulations may change; therefore, the manufacturer should be consulted in cases
where its recommendations appear to conflict.

10. Proper technique for self-injection of insulin and disposal of syringe

Injections are made into the subcutaneous tissue. Most individuals are able to lightly grasp a fold of skin
and inject at a 90° angle. Thin individuals or children can use short needles or may need to pinch the skin
and inject at a 45° angle to avoid intramuscular injection, especially in the thigh area. Routine aspiration
(drawing back on the injected syringe to check for blood) is not necessary. Particularly with the use of
insulin pens, the needle should be embedded within the skin for 5 s after complete depression of the
plunger to ensure complete delivery of the insulin dose.

Patients should be aware that air bubbles in an insulin pen can reduce the rate of insulin flow from the
pen; underdelivery of insulin can occur when air bubbles are present, even if the needle remains under
the skin for as long as 10 s after depressing the plunge

If an injection seems especially painful or if blood or clear fluid is seen after withdrawing the
needle, the patient should apply pressure for 5–8 s without rubbing. Blood glucose monitoring should be
done more frequently on a day when this occurs. If the patient suspects that a significant portion of the
insulin dose was not administered, blood glucose should be checked within a few hours of the injection. If
bruising, soreness, welts, redness, or pain occur at the injection site, the patient’s injection technique
should be reviewed by a physician or diabetes educator. Painful injections may be minimized by the
following:

a. Injecting insulin at room temperature.

b. Making sure no air bubbles remain in the syringe before injection.
c. Waiting until topical alcohol (if used) has evaporated completely before injection.
d. Keeping muscles in the injection area relaxed, not tense, when injecting.
e. Penetrating the skin quickly.
f. Not changing direction of the needle during insertion or withdrawal.
g. Not reusing needles.

 With on hand stabilize the skin by spreading it or pinching up a large area. Pick up syringe with
the other hand and hold it as you would a pencil.
 Insert the needle straight in to the skin.
 To inject the insulin, push the plunger all the way in.
 Pull the needle straight out of skin. Press cotton ball over injection site for several seconds.
 Use disposable syringe only once and discard into hard plastic container (with a tight-fitting top)
such as empty bleach or detergent container. Follow state regulations for disposal of syringes
and needles

Disposal
 Regulations in some states require the destruction of used insulin syringes and needles.
Recapping, bending, or breaking a needle increases the risk of needle-stick injury. Unless the syringe will
be reused, it should be placed in a puncture-resistant disposal container or needle-clipping device, which
retains the clipped needle in an inaccessible compartment. In areas with container-recycling programs,
placement of containers of used syringes, needles, and lancets with materials to be recycled is prohibited.
Local trash disposal authorities should be consulted to determine the appropriate disposition of such
containers. The likelihood of reuse of a syringe by another person is decreased if the plunger is separated
from the barrel at the time of disposal. Disposable insulin pens that contain a limited capacity (e.g., 150 or
300 units) of insulin are available. Users select the dose, inject the insulin, and then discard the needle
according to local regulations. After all of the insulin has been used, the pen device can be discarded in
the garbage can with regular trash.

11. Dawn Phenomenon is characterized by a relatively normal blood glucose level until approximately 3am,
when blood glucose levels begin to rise. The phenomenon is thought to result from nocturnal surges in
growth hormone secretion, which create a greater need for insulin in the early morning hours in patients
wit type 1 diabetes. It is treated by Changing the time of injection of evening intermediate-acting insulin
from dinnertime to bedtime.
The Somigyi Effectis characterized by normal or elevated blood glucose at bedtime, a decrease at
2-3am to hypoglycemic levels and a subsequent increase caused by the production of counterregulatory
hormones. It is treated by Decreasing evening (predinner or bedtime) dose of intermediate-acting insulin,
or increase bedtime snack.

12. First, i will discuss their illness, its causes and prevention.Then i will eduate patient about CBG and he
importance of monitoring, controlling and maintaining the level of their blood glucose. The patient should
test blood glucose levels pre-meal and post-meal can help the patient with diabetes make better food
choices (Patients with diabetes need to maintain a healthy diet consisting of multiple servings of fruits,
vegetables, whole grains, low-fat dairy products, fish, lean meats, and poultry. ), based on how their
bodies are responding to specific foods. Patients should be taught specific directions for obtaining an
adequate blood sample and what to do with the numbers that they receive. The patient will be taught to
take and monitor CBG and symptoms felt with time and date indicated. I will help the patient plan their
daily activities, diet and administration of insulin and other oral medications and the importance of taking
medications exactly as prescribed, in the appropriate dose. Patients should be provided with a list of signs
and symptoms of hypoglycemia and hyperglycemia and actions to take in each situation.  It is important
to teach the patient on what to eat and what to avoid like smoking. Patients whould also be aware of
cholesterol and lipid management, blood pressure monitoring and management and management of
other disease processes. . Proper skin and foot care is needed to avod bruising and sores. I will show the
patient how to properly administer insulin by themselves. I will teach patients about further complications
that may happen for DM patients and ask them to takes steps to prevent eye disease. Inform the patient
to report any signs or symptoms instantly so that action can be started. I will encourage the patient and
his family to have a regular exercise that can improve the functioning of the cardiovascular system,
improve strength and flexibility, improve lipid levels, improve glycemic control, help decrease weight, and
improve quality of life and self-esteem.