DIABETES MELLITUS

Scenario:
E.B., a 69-year-old man with type 1 diabetes mellitus (DM), is admitted to a large regional
medical center complaining of severe pain in his right foot and lower leg. The right foot and lower leg are
cool and without pulses (absent by Doppler). Arteriogram demonstrates severe atherosclerosis of the right
popliteal artery with complete obstruction of blood flow. Despite attempts at endarterectomy and
administration of intravascular alteplase (tissue plasminogen activator [TPA]) over several days, the foot
and lower leg become necrotic. Finally, the decision is made to perform an above-the-knee amputation
(AKA) on E.B.'s right leg. E.B. is recently widowed and has a son and daughter who live nearby. In
preparation for E.B.'s surgery, the surgeons wish to spare as much viable tissue as possible. Hence, an
order is written for E.B. to undergo 5 days of hyperbaric therapy for 20 minutes bid.

QUESTION:
1. What is the purpose of hyperbaric therapy?
ANSWER:
1. Hyperbaric oxygen therapy increases the amount of oxygen your blood can carry. An increase in
blood oxygen temporarily restores normal levels of blood gases and tissue function to promote
healing and fight infection. Hyperbaric oxygen therapy is used to treat several medical conditions.

Case study progress:

As you prepare E.B. for surgery, he is quiet and withdrawn. He follows instructions quietly and
slowly without asking questions. His son and daughter are at his bedside, and they also are very quiet.
Finally, E.B. tells his family, “I don't want to go like your mother did.
She lingered on and had so much pain. I don't want them to bring me back.”

QUESTIONS:

1. You look at his chart and find no advance directives. What is your responsibility?
2. What is your assessment of E.B.'s behavior at this time?
3. What are some appropriate interventions and responses to E.B.'s anticipatory grief?

ANSWER:
1. Notify the case manager so that one is attained. Notify doctor of the patient’s personal
preferences.
2. Ineffective health maintenance related to ineffective coping skills; anxiety related to fear of pain
and the possibility of death.
3. Establish therapeutic relationship by encouraging the patient to express his feelings and involving
him in the plan of care. Explain the risks and benefits of the procedures, giving him accurate
information about condition and therapies. Arrange a social worker to assist him with resources
such as educational and emotional support groups.
 Case study progress:

E.B. returns from surgery with the right stump dressed with gauze and an elastic wrap. The
dressing is dry and intact, without drainage. He is drowsy with the following vital signs (VS): 142/80, 96,
14, 97.9 ° F (36.6 ° C), Spo2 92%. He has a maintenance IV of D5NS infusing at 125 mL/hr in his right
forearm.

QUESTIONS:

1. The surgeon has written to keep E.B.'s stump elevated on pillows for 48 hours; after that, have him lie
in a prone position for 15 minutes, four times a day. In teaching E.B. about his care, how will you
explain the rationale for these orders?

2. In reviewing E.B.'s medical history, what factors do you notice that might affect the condition of his
stump and ultimate rehabilitation potential?

ANSWERS:
1. It will stretch the flexor muscles to facilitate mobility and prevent muscle atrophy.
2. Uncontrolled DM1 and atherosclerosis.

Case study progress:

You have just returned from a 2-day workshop on guidelines for the care of surgical patients with
type 1 DM. You notice that E.B.'s daily fasting blood glucose has been running between 130 and 180
mg/dL. The sliding-scale insulin intervention does not begin until blood glucose values equal to or greater
than 200 mg/dL are reported. You recognize that patients with blood glucose values even slightly above
normal suffer from impaired wound healing.

QUESTIONS:

1. Identify four interventions that would facilitate timely healing of E.B.'s stump.
2. What should the postoperative assessment of E.B.'s stump dressing include?
3. You are reviewing the plan of care for E.B. Which of these care activities can be safely delegated to
the nursing assistive personnel (NAP)? (Select all that apply.)
a. Rewrapping the stump bandage
b. Checking E.B.'s vital signs
c. Assessing E.B.'s IV insertion site
d. Assisting E.B. with repositioning in the bed
e. Asking E.B. to report his level of pain on a 1-to-10 scale

4. On the evening of the first postoperative day, E.B. becomes more awake and begins to complaining
of (C/O) pain. He states, “My right leg is really hurting; how can it hurt so bad if it's gone?” What is
your best response?
a. . “That is a side effect of the medication.”
b. “You can't be feeling that because your leg was amputated.”
 c. “Don't worry, that sensation will go away in a few days.”
d. “Are you able to rate that pain on a scale of 1 to 10?”
5. What is causing E.B.'s pain?

ANSWERS:
1. Four interventions that would facilitate timely healing of E.B.'s stump:
a. Maintain dressing dry and clean.
b. Monitor for signs and symptoms of infection.
c. Apply elastic wraps to shrink and reshape the residual extremity into a cone.
d. Follow wound care as ordered by the doctor.
2. Assess wound drainage for color, amount and the presence of odor.
3. You are reviewing the plan of care for E.B. Which of these care activities can be safely delegated to
the nursing assistive personnel (NAP)? (Select all that apply.)
a. Rewrapping the stump bandage
b. Checking E.B.'s vital signs
c. Assessing E.B.'s IV insertion site
d. Assisting E.B. with repositioning in the bed
e. Asking E.B. to report his level of pain on a 1-to-10 scale
4. On the evening of the first postoperative day, E.B. becomes more awake and begins to complaining
of (C/O) pain. He states, “My right leg is really hurting; how can it hurt so bad if it's gone?” What is
your best response?
a. “That is a side effect of the medication.”
b. “You can't be feeling that because your leg was amputated.”
c. “Don't worry, that sensation will go away in a few days.”
d. “Are you able to rate that pain on a scale of 1 to 10?”
5. Phantom limb pain is the sensation of pain from a limb that was amputated, the feeling of pain comes
from the spinal cord and the brain.

Case study progress:

The case manager is contacted for discharge planning. E.B. will be discharged to an extended
care facility for strength training. Once the patient receives his prosthesis, he will receive balance
training. After that, he will be discharged to his daughter's home. A physical therapy and occupational
therapy home evaluation should be ordered.

QUESTIONS:

1. What instructions should be given to E.B.'s daughter concerning safety around the home?

ANSWERS:

1. Keep walkways free of clutter, install assistive bars/rails, keep walkway to restroom lit for the
patient to avoid accidents at night.
 ACTIVITY

1. What are the complications related to Diabetes Mellitus type 1?

Over time, type 1 diabetes complications can affect major organs in your body, including heart,
blood vessels, nerves, eyes and kidneys. Maintaining a normal blood sugar level can dramatically
reduce the risk of many complications.

Eventually, diabetes complications may be disabling or even life-threatening.

 Heart and blood vessel disease. Diabetes dramatically increases your risk of various
cardiovascular problems, including coronary artery disease with chest pain (angina), heart
attack, stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.
 Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels
(capillaries) that nourish your nerves, especially in the legs. This can cause tingling,
numbness, burning or pain that usually begins at the tips of the toes or fingers and
gradually spreads upward. Poorly controlled blood sugar could cause you to eventually
lose all sense of feeling in the affected limbs.

Damage to the nerves that affect the gastrointestinal tract can cause problems with nausea,
vomiting, diarrhea or constipation. For men, erectile dysfunction may be an issue.

 Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel
clusters that filter waste from your blood. Diabetes can damage this delicate filtering
system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease,
which requires dialysis or a kidney transplant.
 Eye damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy),
potentially causing blindness. Diabetes also increases the risk of other serious vision
conditions, such as cataracts and glaucoma.
 Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of
various foot complications. Left untreated, cuts and blisters can become serious infections
that may ultimately require toe, foot or leg amputation.
 Skin and mouth conditions. Diabetes may leave you more susceptible to infections of the
skin and mouth, including bacterial and fungal infections. Gum disease and dry mouth
also are more likely.
 Pregnancy complications. High blood sugar levels can be dangerous for both the mother
and the baby. The risk of miscarriage, stillbirth and birth defects increases when diabetes
isn't well-controlled. For the mother, diabetes increases the risk of diabetic ketoacidosis,
diabetic eye problems (retinopathy), pregnancy-induced high blood pressure and
preeclampsia.
 2. What is the medical management of Diabetes Mellitus type 1 in terms:
a. pharmacological therapy in MNEMONICS form

DIABETES MELLITUS DRUGS STUDY

NAME OF MECHANISM DOSAGE INDICATIONS CONTRAINDICATIONS ADVERSE NURSING ALERT

DRUGS OF REACTION
ACTION
Sulfonylureas  Sulfonylurea GLIMEPIR Sulfonylureas are  type I diabetes  The most common  Watch for hypoglycemia
s act mainly IDE used primarily (where patients lack adverse effects of Teach pt. S&S and how to
by increasing (AMARYL for the treatment pancreatic β-cells) sulfonylureas are prevent.
the release of ®) of diabetes mellit  Use with caution in hypoglycemia, 
insulin from Tablet us type 2. patients with  weight gain, and  Use with caution in pts.
the pancreatic  1 mg Sulfonylureas are significant hepatic risk for with renal/liver
β-cells in  2 mg ineffective where impairment (due to a cardiovascular dysfunction.
response to  4 mg there is absolute high risk for events. Clinicians
stimulation by Type 2 deficiency of hypoglycemia). initially prescribe
glucose They diabetes insulin o SFUs undergo lower doses of  Lower incidence of
bind to the Starting: 1 - production such hepatic metabolism sulfonylureas to hypoglycemia with
sulfonylurea  2 mg once as in type  Use with caution in prevent the risks Amaryl.
receptor daily 1 diabetes or patients with renal of hypoglycemia.
SUR1, which Maintenanc post- insufficiency (increases Unfortunately, in
closes the e: 2 - 8 mg pancreatectomy. the risk for some patients
KATP once daily Sulfonylureas can hypoglycemia) taking
channel in the Max: 8 mg be used to treat o Some SFUs have sulfonylureas, the
β-cell once daily some types of active metabolites adverse effects
membrane. Increase neonatal diabetes that undergo renal may outweigh the
dose in clearance benefits
increments  Caution in elderly
of 1 - 2 mg a patients (in whom
day at hypoglycemia may be
intervals of 1 especially dangerous)
- 2 weeks
Take with
first main
meal of the
day
Insulin  Inhibits  All Below are the following Hypoglycemia’s are
breakdown of patients contraindications for the main problem,  Be certain to give the
fat in adipose with type I patient taking Insulin: especially in correct type of insulin.
tissue by diabetes  Diarrhea, fever, intensified treatment.
inhibiting the mellitus. infection, surgery, Excessive doses,  Prepare the correct dosage.
intracellular  Patients thyroid disease, insufficient calory Have another nurse
lipase that with type II trauma, vomiting uptake, or physical double-check the dose
hydrolyzes diabetes exertion are possible before you administer the
triglycerides mellitus in  Hepatic disease, renal triggers. Early injection.
to release whom control failure, renal symptoms: hunger,
fatty cannot be impairment restlessness, sweating  Use the correct syringe.
acids. Insulin  adequately or vertigo, Never use a regular
facilitates achieved with  Intramuscular unsteadiness and syringe for insulin. Use a
entry of oral administration, thought disorders. syringe calibrated in
glucose into hypoglycemics intravenous Specialists do not “units.”
adipocytes,  Or diet. administration agree if human insulin
and within  Patients hinders the timely
those cells, with diabetes i  Continuous recognition of severe
glucose can n pregnancy in subcutaneous insulin hypoglycemia more
be used to whom control infusion (CSII) often than animal
synthesize is inadequate administration insulins.
glycerol. with diet.
 In  Hypoglycemia Considerable weight
situations of gain is often observed
stress, such as  Hypokalemia under the intensified
surgery, after treatment. Generalized
myocardial hypersensitive
 Cresol hypersensitivity
infarction, etc. reactions also occur
with human insulin. A
 Labor, neonates,
lipodystrophy can
obstetric delivery,
occur at the site of
pregnancy
injection. Transient
visual disturbances are
possible after
readjustments.
 10-16 years; Known hypersensitivity to  Common adverse
Metformin  Metformin d Initial 500 Metformin hydrochloride, effect includes  Monitor urine or
ecreases mg orally, Metformin is renal disease or renal anorexia, nausea, serum glucose levels
hepatic every 12 primarily suited dysfunction, cardiovascular vomiting, frequently to
glucose hours, for the treatment collapse or shocks, acute flatulence, asthenia, determine
production, increase of subjects myocardial infarction, indigestion. effectiveness of drug
decreases every week with non-insulin- septicemia, congestive and dosage.
intestinal by 500 mg. dependent heart failure requiring  Others: lactic
absorption of MAX: 2000 diabetes pharmacologic treatment, acidosis (rare)  WARNING: Arrange
glucose, and mg/day mellitus (type II acute or metabolic acidosis hypoglycemia, low for transfer to insulin
improves 17 years; diabetes). including diabetes serum vitamin B12 therapy during periods
insulin Initial 500 Compared to ketoacidosis with or levels, chills, of high stress
sensitivity by mg orally, other antidiabetic without coma are dizziness. (infections, surgery,
increasing every 12 or agents, it has the contraindications for its trauma).
peripheral 850 mg/day advantages of use.
glucose with meal. lowering rather
uptake and Maintenance than increasing  WARNING: Use IV
utilization. 1500-2550 body weight, glucose if severe
mg/day in 2- of not causing hypoglycemia occurs
3 divided hypoglycemia, as a result of overdose.
doses with and of entailing a
meal. reduction of
Max dose; triglycerides and
2550 LDL-cholesterol
mg/day. levels. Metformin
is therefore
recommended
in single drug
therapy especiall
y for obese
subjects. In the
majority of the
treated subjects, a
lowering of blood
glucose levels by
at least 25% is
achieved (i.e.
almost identical
results as with
sulfonylureas at
the beginning of
treatment).
 NURSING CARE PLAN FOR DIABETES MELLITUS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE DATA:  Fluid and  After 8 hours of nursing  Pt will be started on  After 8 hours of nursing
“I extremely get thirst and Electrolyte intervention, the an Insulin gtt and intervention, the
frequent urination since last Imbalance related patients must achieve blood sugars will be patients must achieve
Sunday when I attend super to diabetes as check every hour
optimal level of diabetic optimal level of
bowl party” as stated by the evidence by per md order until
patient. Glucose 636 and diet and minimize the pt’s blood sugars diabetic diet and
K+ 2.9. risk of complication of are 80-150.-Pt will minimize the risk of
diet and the patient will be given potassium complication of diet
verbally state the supplementation per and the patient will
OBJECTIVE DATA: importance of diabet6ec md order and a verbally state the
diet or take diabetes BMP will be drawn importance of diabet6ec
VS: 1 hour after
diet. diet or take diabetes

HR 106 potassium
diet.

BP 108/68 supplementation is

O2 Sat 97% on RA given to check K+.
25  -The nurse will
Upon assessment: verbalize and
 Sunken eyes provide printed
 Skin turgor greater material to pt. on
than 3 seconds the side effects of
 Fruity breath smells un-managed
 Dry and flushed diabetes.
skin  – The nurse will
demonstrate to the
pt. how to check
blood sugars and
give insulin
injections properly
and will ask the
patient to
reciprocate.
3.Make a nursing care management of the patient with Diabetes Mellitus type 1.

NURSING CARE PLAN FOR DIABETES MELLITUS

3.
 4. . Make a pathophysiology of type 2 diabetes

PATHOPHYSIOLOGY OF TYPE 2 DIABETES

Genetic predisposition
Environmental factors

Autoantigens form on insulin-producing beta cells and circulate

in the blood stream and lymphatics

Processing and presentation of autoantigen of antigen presenting cells

Activation of T helper 1 lymphocytes Activation of T helper 2 lymphocytes

Activation of macrophages Activation of autoantigen-

Activation of B lymphocytes to produce islet
With release of IL-1 and TFN Specific T cytotoxic (CD8) cells
cells autoantibodies and antiGAD antibodies

Destruction of beta cells with decreased insulin secretion