Diabetes Mellitus: Pamela Krupilis RN MSN Cns Joseph F. Mccloskey School of Nursing

Slide 1
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Diabetes Mellitus
Pamela Krupilis RN MSN CNS
Joseph F. McCloskey School of
Nursing
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Joseph F. McCloskey School of Nursing
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Slide 2
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Slide 3
Diabetes Mellitus
Pancreas - Large fish-shaped organ behind the stomach.
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Islets of Langerhans - Cells located thru-out the pancreas.

Produce Alpha ( ) and Beta ( )
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Slide 4
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Beta Cells - Synthesize insulin (a hormone) -- lowers blood
sugar.
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Insulin is the key that unlocks the cell to allow glucose to move from the
blood stream into the cell.
Alpha Cells - Synthesize glucagon (also a hormone) -- raises

blood sugar
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Glucagon promotes conversion of glycogen (glucose stored in the liver) to

glucose.
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Slide 5
Vocabulary
Gluconeogenesis - Production of new glucose from amino
acids.
Glycogenolysis - Glycogen breakdown in the liver through the
action of glucagon
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Slide 6
Functions of Insulin
1. Promotes the transport of glucose from the bloodstream
across the cell membrane.
Receptor sites on cells necessary for this to happen.
In DM
Too few receptor sites (insulin resistance)
Too little insulin
No insulin
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Slide 7
2. Glycogen breakdown in the liver through the action of
glucagon
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CHO
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PROTEIN
FAT
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Slide 8
3. Promotes storage of excess glucose in the liver (glycogen).
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Counterregulatory Hormones
Glucagon
Epinephrine
Growth Hormone
Cortisol
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Diabetes Mellitus
According to CDC (2011):
26 million people have diabetes and another 7 million dont
know they have it.
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79 million people have pre-diabetes.

7th leading cause of death in US
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Slide 11
Diabetes
Defined as: A chronic disease of metabolism
caused by an imbalance between insulin supply
and demand
Characterized by:
Hyperglycemia
Abnormal metabolism of CHO, fat, and
protein.
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Slide 12
Types of Diabetes
Type I -- Insulin Dependent
Type II -- Non-Insulin
Dependent
Secondary (Medical condition and/or medications)
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Gestational (GDM)
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Slide 13
Pre-diabetes
79 million people have it.
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BS > 100 but < 126 when fasting

Will usually develop Type II within 10 years.
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Can greatly reduce risk by weight loss and diet

Some PCP prescribe oral diabetic meds.
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Slide 14
Type I (IDDM)
10% of all diabetics
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40 years old
thin
incidence peaks at age 12 (40% of children with diabetes are less than 2
years old).
highest among people of European origin.
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Slide 15
Type I (IDDM)
Genetic predisposition.
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However, most (90%) type I diabetics do not have a firstdegree relative with DM.
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Slide 16
Type I (IDDM)
1. Genetic predisposition HLA markers
2. Environmental triggers spring and fall viral?
3. Active autoimmunity development of islet cell

antibodies (ICA) and insulin antibodies.
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4. Progressive beta cell destruction (usually takes

80 90% destroyed before DM occurs.
5. Overt DM depend upon exogenous source of
insulin.
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Slide 17
Type I (IDDM)
Manifestations
Polyuria, Polydipsia, & Polyphagia
Weakness & fatigue
Weight loss
Ketoacidosis
Ketonuria
Glycosuria
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Slide 18
Type 2 (NIDDM)
90% of diabetics are type II
40 years old
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dramatic increase over past 40 years

especially among Blacks, Hispanics, and Native Americans
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Obese
In 2001, epidemic among those in their 30s
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Type 2 (NIDDM)
Manifestations
Often nonspecific/asymptomatic
Polydipsia, Polyphagia, Polyuria
Fatigue, skin infections, recurrent candidal infection
Prolonged healing, visual changes
Pruritis
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Slide 20
Four Metabolic Abnormalities
1. Insulin Resistance
2. The inability of pancreas to produce insulin
3. Decrease production of glucose by the liver
4. Altered production of hormones & cytokines by adipose
tissue
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Slide 21
Metabolic Syndrome
Cluster of abnormalities that greatly increased risk for the
development of type 2 DM.
Increased risk for type 2 DM
Characterized by: insulin resistance, elevated insulin levels,
high levels of triglycerides, decreased HDL, increased LDL &
HTN.
Risk factors: obesity, sedentary, ethnicities
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Slide 22
Gestational Diabetes
Occurs during pregnancy

Increase risk to develop type 2DM in 5-10 years after delivery.
Nutritional therapy first line of treatment
May need to add insulin therapy.
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Slide 23
Secondary (other) Diabetes

Secondary to other medical condition
Medications
Diabetes risk test available at
www.diabetes.org/risk-test.jsp
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Slide 24
Diagnostic Studies
Glycosylated Hemoglobin A1C 6.5%

Fasting plasma glucose (FPG) level 126 mg/dL
2 hour Oral Glucose Tolerance Test (OGTT) 200 mg/dL
Classic symptoms of hyperglycemia and a random plasma
glucose level 200 mg/dL
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Slide 25
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Estimated Blood Glucose
Estimated Blood Glucose (eAG) =
28.7 X A1C 46.7
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A1C 7.5% = eAG of 169 mg/dL
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http://professional.diabetes.org/glucosecalculato
r.aspx
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Slide 26
OGTT
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Slide 27
Diabetes Management
Education
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Diet
Exercise
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BGM
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Medication
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Diet
Food pyramid Healthy American Diet

Approximately 30% Type II controlled by diet
Standard size servings for adults:
Beef: 3 ounce serving (approximately size of 3 middle fingers)
Pork: approximately size of 3 middle fingers and part of palm.
Fish: 3 middle fingers and all of palm
Vegetables: small fruit bowl.
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Diet
Daily amt
Carbs
Min 130g/day
Sugars, starches & fiber
Fats
Sat <7%
Chol <200mg/d
Carries fat-soluble vits &

provides essential fatty
acids
Protein
15%-20%
High protein diets are not

recommended for ppl
with DM
Fiber
14g/1000kcal
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Diet
CHO Count
Exchange Diet
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Read Food Labels.
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Slide 31
Diet
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Alcohol
Can cause hypoglycemia depends upon severity of diabetes and
glycemic control.
Need to consult with physician / nurse.
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Slide 32
Diet
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Sugar Substitutes
Safe for use
Sucrose, fructose, honey, corn syrup, molasses, fruit juice,
maltose, dextrose.
If 20 calories, considered Free
Sorbitol and other sugar alcohols have laxative effect.
Non-nutritive sweeteners have no calories aspartame,
saccharin.
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Slide 33
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Exercise
Regular exercise program reduces insulin requirements by as much as 10%.
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Increased insulin uptake by muscle cells can lead to hypoglycemia.
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Slide 34
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Blood Glucose Monitoring
Glycosylated Hemoglobin (HbA1C) 90 to 120 day
average
Good metabolic control:
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HbA1C < 7%
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Slide 35
Blood Glucose Monitoring (FSBS)
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QID, AC, & HS

Q 6 hours if NPO (surgery) or on continuous
parenteral nutrition or tube feedings.
Diabetic Control and Complication Trial (DCCT)
Intensive therapy
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2 4x/day (pre-meal, 2 hr pc, 3 am)

4 8x/day for intensive management
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Slide 36
Pancreas Transplantation
Type 1 DM
ESRD who plan to have a kidney transplant
Kidney & Pancreas transplants are performed
together
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Stress & Surgery

Emotional & physical stress
May need extra insulin
Acute illness, injury, and surgery
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Medications
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Insulin
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Oral Hypoglycemics
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Oral antihyperglycemics
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Slide 39
Insulin - Inspection
Clear
Humulin R
Lispro (Humalog)
Lantus (Glargine)
No clumps or discoloration
Check expiration date!
Cloudy
All other Insulins mixed with protamine zinc
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Slide 40
Insulin Regimen
Intensive Insulin Therapy

Goal 80-120mg/dL before meals
Mealtime Insulin (Bolus)
Basal Insulin
Review Table 49-4
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Slide 41
Insulin - Storage
Refrigerate
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Stable at room temperature

Open vial good for 1 month
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Keep out of direct light and heat

Always have a spare vial on hand
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Slide 42
Insulin - Needles
Available in 28-31 gauge with 1/2 and 5/16
needle
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Not recommended to re-use

Cleansing with alcohol will remove silicone
coating
risk of infection with re-use, especially if poor
hygiene / sanitation
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Insulin - Needles
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New needle
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Needle after 2 uses
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Insulin - Syringes
Available in 0.3 ml, 0.5 ml, and 1ml
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Pre-filled Syringes
Stable in frig for up to 3 weeks
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Store needle up
Gently roll to distribute insulin in suspension
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Slide 46
Site Selection
Rate of absorption
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Abdomen
Arms
Legs
Rotate site in same area an inch apart
Variable absorption rates
Exercises involving arms / legs may absorption
hypoglycemia
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Slide 47
Sources of Insulin
Beef (Bovine) -- NOT AVAILABLE in US
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Pork (Porcine) -- NOT AVAILABLE IN US

Human recombinant DNA
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Slide 48
Type of Insulin Rapid Acting

lispro (Humalog), aspart (Novolog), glulisine (Apidra)
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Faster acting than Regular
immediate onset, peaks 0.5 to 1.5 hours, duration 2 to 4 hours

Give immediately before eating !!
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not approved for IV use

used when PEAK action more important than duration
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Slide 49
Types of Insulin Short Acting

Regular (Humulin R, Novolin R)
onset 15 to 1 hour, peak 2 - 4 hours, duration 3

- 6 hours
Give 30 to 60 minutes AC
Only Insulin approved for IV use
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may be given IM if IV not available
sticks to IV bag and tubing
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Slide 50
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Types of Insulin Intermediate
Acting
Humulin N
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NPH (Natural Protamine Hagedorn)

peak 4 - 6 hours, duration 10 - 16 hours
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Lente- peak 6 8 hours
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Types of Insulin Long Acting

Humulin U
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Ultralente peak 18 hrs
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Slide 52
Types of Insulin Long Acting

Lantus (glargine)
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Genetically designed rDNA

24 hour glucose-lowering effect
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Very acid -- therefore

cannot be mixed with other insulin
causes burning with injection
Do not give in same injection site
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Slide 53
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Insulin Type
Start
Peak
Duration
Less than
15 min
0.5 1.5 hr
2 6 hrs
Rapid Acting
Humalog (Lispro)
Novolog (Aspart)
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Same as rapid
Exubera (Inhaled Insulin)
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Short Acting
Humilin R / Novolin R
- 1 hr
2 3 hrs
3 10 hrs
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Slide 54
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Intermediate Acting
Humulin N / Humulin L (Lente)
2 - 4 hrs
4 10 hrs
10 18 hrs
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Novolin N
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Slide 55
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Long Acting
Humulin U (Ultralente)
6 10 hrs
8 20 hrs
(variable)
18 24 hrs
Lantus (Glargine)
4 8 hrs *
Little Peak *
24 hrs
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ATI Med Surg Review, version 7.0 (2007), p. 586

* these times are NOT noted in the ATI med-surg review book.
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Premixed Insulins
Humulin 70/30 70% N + 30% R
Humulin 50/50 50% N + 50% R
Humalog 75/25 75% N + 25% Humalog
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Slide 56
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Insulin Pens
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Slide 58
Insulin Pens
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Slide 59
Somogyi Effect
Rebound hyperglycemia.
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Caused by too much insulin which results in

hypoglycemia.
Hypoglycemia triggers the release of counter
regulatory hormones (glucagon) which causes
early morning hyperglycemia.
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Problem is that patient may take even more insulin

to cover the rebound hyperglycemia.
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Slide 60
Dawn Phenomenon
Hyperglycemia upon awakening in the morning
Possible R/T cortisol & GH
Affects majority of DM patients.
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Slide 61
Oral Hypoglycemic Agents

Primary Site
Action
Pancreas
stimulates pancreas to increase insulin

production
Liver
suppresses glucose production in the

liver
Muscle
works at receptor site on muscle cells to

improve effectiveness of insulin
Bowel
inhibits glucose absorption
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Slide 62
Sulfonylureas
glipizide (Glucotrol, Glucortol XL); glyburide (Micronase, DiaBeta,

Glynase); glimepiride (Amaryl)
Action: Stimulates release of insulin form the pancreas, decreases hepatic
production of glucose, & increases cellular sensitivity to insulin
Side Effects: renal or hepatic insufficiency, GI effects, weight gain,
Hyponatremia & SIADH, hypoglycemia,
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Slide 63
Meglitinides
repaglinide (Prandin) & nateglinide (Starlix)
Action: Increase production of insulin from the pancreas
Side Effects: weight gain, hypoglycemia
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Slide 64
Biguanide
metformin (Glucophage, Glucophage XL, Riomet,
Fortamet, Glumetza)
Action: decreases hepatic glucose production,
increases insulin sensitivity in adipose & skeletal tissue,
& decreases intestinal absorption of glucose. It also
lowers triglyceride levels & LDL, & promotes weight
loss.
Side Effects: GI disturbances, aplastic anemia, vitamin B
12 def, agranulocytosis, thrombocytopenia & Lactic
Acidosis
Contraindications: heart failure, hepatic & renal
function impairment
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Slide 65
-Glucosidase Inhibitors
acarbose (Precose) & miglitol (Glyset)
Known as Starch Blocker
Action: slow down the absorption of
carbohydrates in the small intestine.
Side Effects: flatulence, abd pain, diarrhea
Contraindicated: IBD, colonic ulceration, hx of
bowel obstruction, liver & renal impairment
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Slide 66
Thiazolidinediones
pioglitazone (Actos) & rosiglitazone (Avandia)
Referred as insulin sensitizers
Action: decreases endogenous glucose
production & increases insulin sensitivity,
transport, utilization at target tissues.
Side Effects: weight gain, edema, increased
risk for CV events such as MI or CVA
Do not use in patients with symptomatic HF or
with active Liver Disease
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Slide 67
Dipeptidyl Peptidase-4(DPP-4)
Inhibitor
sitagliptin (Januvia) & saxagliptin (Onglyza)
Action: Enhances the incretin system,
stimulates release of insulin, & decreases
hepatic glucose production
Newest class of oral hypoglycemic
medications
Side Effects: URI, sore throat, headache, UTI,
diarrhea, abd pain, nausea, & peripheral
edema
Drug Interaction: Digoxin
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Slide 68
Combination Therapy
Gluvance (metformin & glyburide)

Avandamet (Avandia & metformin)
Metaglip (metformin & glipizide)
Duetact (Actos & Amaryl)
Actoplus Met (metformin & Actos)
Janumet ( metformin & Januvia)
Prandimet (metformin & Prandin)
Avandaryl (Avandia & Amaryl)
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Slide 69
Incretin Mimic
exenatide (Byetta) & liraglutide (Victoza)
Action: stimulates release of insulin; decreases
glucagon secretion; improves satiety;
decreases gastric emptying
Side Effects: nausea, vomiting, hypoglycemia,
diarrhea, headache, pancreatitis, & renal
failure
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Slide 70
Amylin Analog
pramlinitide (Symlin)
Action: gastric emptying; glucagon
secretion; glucose production from the liver;
satiety
Indicated for type 1 & type 2 DM
Administered subcutaneously in thigh or
abdomen.
Can cause severe hypoglycemia when
administered with insulin
Side Effects: hypoglycemia, nausea, vomiting,
decreased appetite, & headache
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Slide 71
Glucose Elevating Agents

Glucagon (GlucaGen)
Action: stimulates glycogenolysis, exerts
positive inotropic & chronontropic effect, &
relaxes GI smooth muscle
Administered IM, IV, or subcutaneous,
Side Effects: hypotension, respiratory distress,
N&V, hypokalemia in overdosage, urticaria
Drug Interactions: Oral anticoagulants
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Slide 72
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Hypoglycemia
Defined as BS < 70.
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BS = stress.
Glucagon and epinephrine

released.
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Called counter-regulatory
hormones released to counter
effects of low BS.
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Slide 73
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Hypoglycemia
Glucagon stimulates
breakdown of stored
glucose (glycogenolysis) in
the liver.
Epinephrine responsible for

s / s of mild hypoglycemia
(early warning system).
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Slide 74
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Hypoglycemia
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Epinephrine necessary for

s / s of hypoglycemia.
This protective mechanism
lost in 25% of all diabetics
(4-6 cups coffee/day help?).
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Lost in 50% of all who have

had DM > 20 years.
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Slide 75
Clinical Manifestations
Mild Symptoms
Caused by release of Epinephrine
Shakiness
Irritability
Nervousness
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Hunger
Tachycardia, maybe some palpitations
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Slide 76
Moderate Symptoms
Diaphoresis
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Pallor
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Paresthesia
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Slide 77
Neuroglycopenic Symptoms
Caused by decreased glucose getting

to the brain
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Headache
Inability to concentrate
Slurred speech
Unsteady gait / maybe a staggering gait
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Double / blurred vision
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Slide 78
Neuroglycopenic Severe Symptoms
Confusion
Irrational behavior / appears as a mental
illness
Combativeness
Lethargy
Loss of consciousness
Coma
Seizure
Death
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Slide 79
Procedure to follow
for
Treatment of
Hypoglycemia
When symptoms
recognized
*BGM, then
For mild to moderate

Non-neuroglycopenic
hypoglycemia
Give fast CHO

Repeat BGM in 15
minutes and give
another fast CHO if <
70
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if no BGM available,
safer to presume
hypoglycemia and
treat !
in many hospitals
and patient care
settings, BGM is not
available!
Slide 80
Procedure to follow
for
Treatment of
Hypoglycemia
Night-time
Hypoglycemia
or if meal longer than

an hour away
Give fast CHO followed
by
A longer acting CHO +
protein (such as milk)
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Slide 81
Treatment for
Hypoglycemia
Mild Hypoglycemia
Fast CHO
Like burning newspaper
15 20 Gm
orange juice 4-6 oz

soda 4-6 oz
Low-fat milk 8 oz
candy 6 8 life savers
2 graham crackers
cake icing 2 oz tube (convenient for
travel)
Glucose tablets
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Slide 82
Treatment for
Hypoglycemia
Best!
milk and toast
lactose = quick source
protein = longer lasting source
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Mild Hypoglycemia
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Slide 83
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Treatment for
Hypoglycemia
Slow CHO
Like burning a log
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Peanut butter
Cheese
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Slide 84
20 30 Gm Fast CHO or
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Treatment for
Hypoglycemia
Glucagon, 1 mg sc or IM
Moderate
Hypoglycemia
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Slide 85
Dextrose 50% IV
Treatment for
Hypoglycemia
Glucagon, 1 mg IM or IV
Vomiting occurs frequently following injection
of
Glucagon -- Protective positioning !
Severe Hypoglycemia
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Slide 86
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Hyperglycemia
BS > 150
Factors that BS
Warm, dry skin

Flushed appearance
Nausea
Treatment
Usually treated with

Fast Acting or Rapid
Acting Insulin on a
sliding scale for BS
> 150.
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Slide 87
Complications
Diabetic Ketoacidosis
Most often seen in Type

1 DM, but may be seen in
Type 2 DM.
Precipitating factors:
illness, infection,
undiagnosed Type 1 DM,
inadequate insulin
dosage, & noncompliance
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Slide 88
Complications
Hyperosmolar
Hyperglycemic
Syndrome (HHS)
Occurs with type 2 DM

Precipitating factors:
UTI, pneumonia, sepsis,
acute illness, & newly
dx type 2 DM.
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Slide 89
Complications
Cerebrovascular
Stroke
Cardiovascular
HTN
CAD
Ischemic heart
disease
Myocardial Infarction
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Slide 90
Complications
Diabetic Retinopathy
Visual deficit
Periods of blurred vision
Cataracts
Glaucoma
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Slide 91
Complications
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Slide 92
Complications
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Slide 93
Complications
Peripheral Neuropathy
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Slide 94
Peripheral Neuropathy Treatment

Elavil
(amitriptyline)
Neurontin
(gabapentin)
Cymbalta
(duloxetine)
Lyrica
(pregabalin)
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Slide 95
Amputation
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Slide 96
Complications
Autonomic Neuropathy
Anhydrosis
Absence of / or excessive sweating of feet
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Gastroparesis -- 2 damage to
vagus nerve
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Nausea / vomiting
GERD, bloating
Constipation
Diabetic diarrhea (d/t fermentation of
intestinal contents caused by
peristalsis 2 vagal nerve damage)
Loss of cardiac reflexes

automatic adjustment of heart rate
and BP to activity and position
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Slide 97
Complications
___________________________________
Diabetic Nephropathy
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Frequent UTI
BUN / Creatinine
Nephropathy
Proteinuria
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Slide 98
Complications
Nephropathy
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Slide 99
Complications
Hematology
Decreased blood
components d/t
inadequate protein
metabolism 2 insulin
deficiency
Hgb and Hct
albumin
leukocytes
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Slide 100
Complications
Integumentary
Atrophic skin -- shiny,

thin, hairless, perhaps
even transparent 2 loss
of subcutaneous tissue
(circulation)
Toenails thick and yellow
(fungus)
Great toe pointing inward
toward other toes,
positioned over
Joseph F. McCloskeyperhaps
School of Nursing
2nd toe (hallux valgus
flexor stronger)
Lack of hair on
extremities (circulation)
Yeast infection in
perineal area / beneath
skin folds.
Slide 101
Complications
Charcot Foot
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Slide 102
Complications
Charcot Foot
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Slide 103
Complications
Hallux Vulgus
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Slide 104
Complications
Hallux Vulgus
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Slide 105
Complications
Fungus
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Slide 106
Complications
Toe Ulcer
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Slide 107
Complications
___________________________________
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Slide 108
Complications
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Slide 109
Complications
___________________________________
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Slide 110
Complications
Charcot foot
with neuropathic pressure
ulcer
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Slide 111
Complications
Venous
ulcer
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Slide 112
Complications
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Venous
ulcer
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Slide 113
Complications
Neuropathic
Ulcers
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Slide 114
Complications
Mental illness
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Slide 115
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Diabetes Mellitus: Pamela Krupilis RN MSN Cns Joseph F. Mccloskey School of Nursing

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Diabetes Mellitus: Pamela Krupilis RN MSN Cns Joseph F. Mccloskey School of Nursing

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Slide 1

Joseph F. McCloskey School of Nursing

Islets of Langerhans - Cells located thru-out the pancreas.

Joseph F. McCloskey School of Nursing

Alpha Cells - Synthesize glucagon (also a hormone) -- raises

Glucagon promotes conversion of glycogen (glucose stored in the liver) to

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

79 million people have pre-diabetes.

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

BS > 100 but < 126 when fasting

Can greatly reduce risk by weight loss and diet

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

3. Active autoimmunity development of islet cell

4. Progressive beta cell destruction (usually takes

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

dramatic increase over past 40 years

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Four Metabolic Abnormalities

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Occurs during pregnancy

Joseph F. McCloskey School of Nursing

Secondary (other) Diabetes

Joseph F. McCloskey School of Nursing

Glycosylated Hemoglobin A1C 6.5%

Joseph F. McCloskey School of Nursing

A1C 7.5% = eAG of 169 mg/dL

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Food pyramid Healthy American Diet

Joseph F. McCloskey School of Nursing

Sugars, starches & fiber

Carries fat-soluble vits &

High protein diets are not

Joseph F. McCloskey School of Nursing

Read Food Labels.

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Regular exercise program reduces insulin requirements by as much as 10%.

Increased insulin uptake by muscle cells can lead to hypoglycemia.

Blood Glucose Monitoring (FSBS)

QID, AC, & HS

2 4x/day (pre-meal, 2 hr pc, 3 am)

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Stress & Surgery

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Joseph F. McCloskey School of Nursing

Intensive Insulin Therapy

Joseph F. McCloskey School of Nursing

Stable at room temperature

Keep out of direct light and heat

Joseph F. McCloskey School of Nursing