SPECIFIC DISORDERS OF THE PANCREAS
DIABETES MELLITUS
Data Base
A. General information: Etiology and Pathophysiology
1. Hyperglycemia occurs when there is insufficient
secretion of insulin, cells become insulin resistant,
and/or hepatic glucose production is increased
2. Body attempts to rid itself of excess glucose by
excreting some via kidneys; an osmotic force is created
within the kidneys because of this glucose excretion and
body fluid is lost
3. If the body is unable to use carbohydrates for cellular
function fat is oxidized as a compensatory mechanism;
oxidation of fats gives off ketone bodies
4. Factors that increase blood glucose include:
a. Glucocorticoids
b. Epinephrine
c. Glucagon
d. Somatotropin
e. Emotional stress
f. Pregnancy with multiple births
g. Surgery of trauma
h. Obesity (overeating)
5. Possible causes
a. Autoimmune disease
b. Blockage of insulin supply
c. Cushing’s syndrome
d. Exposure to chemicals
e. Failure of the body to produce insulin
f. Genetics
g. Hyperpituitarism
h. Hyperthyroidism
i. Infection
j. Medications
k. Pregnancy
l. Receptor defect in normally insulin-responsive cells
m. Stress
n. Surgery
o. Trauma
6. Risk factors
a. Type 1: genetic predisposition; environmental
factors such as toxins or viruses, age <30 years
b. Type 2: family history, obesity, usually age >45
years, history of gestational diabetes, increasing
incidence in childhood and adolescence
7. Classification
a. Type 1: formerly known as insulin-dependent
diabetes mellitus (IDDM); destruction of beta cells
leads to an inability to produce insulin; requires
exogenous insulin
b. Type 2: formerly known as non-insulin-dependent
diabetes mellitus (NIDDM); has a gradual onset and
the pancreas produces some insulin so that
ketoacidosis is not likely; may be controlled with
adherence to a diet and exercises program that
promotes maintenance of a desirable weight;
accounts for 90% of diabetes
c. Gestational: detected during 24 to 48 weeks’
gestation; glucose levels are generally normal 6
weeks postpartum; more likely to develop type 2
diabetes 5 to 10 years after delivery; neonate
exhibits macrosomia, hypoglycemia, hypocalcemia,
and hyperbilirubinemia
d. Diabetes mellitus associated with other conditions
or syndromes (formerly known as secondary
diabetes); associated with conditions such as
Cushing’s disease, pancreatic disease, and
glucocorticoid medication
e. Impaired glucose tolerance; high glucose levels but
not sufficiently high to be diagnostic for diabetes
8. Acute increases in serum glucose levels; diabetic
ketoacidosis (DKA) and hyperglycemic hyperosmolar
nonketonic syndrome (HHKS)
a. Causes: insufficient insulin, major stresses (e.g.,
infection, surgery, trauma, pregnancy, emotional
turmoil, nausea and vomiting), or drugs (steroids)
b. Pathophysiology
 DKA is associated with type 1; with inadequate
insulin to support basal needs, proteins and fats
are used; ketones are excreted via urine and
breathing; dehydration and electrolyte
imbalance occur
 HHKS is associated with type 2;
hyperglycemia increases intravascular osmotic
pressure, leading to polyuria and cellular
dehydration
9. Acute decreases in serum glucose: insulin shock or
reaction
a. Causes: excess insulin or oral antidiabetic
medications; too little food or too much exercise
when receiving antidiabetic medications
b. Pathophysiology: excessive insulin lowers serum
glucose as glucose is carried into cells; decreased
food intake in relation to prescribed antidiabetic
medications results in hypoglycemia; excessive
exercise uses glucose for metabolism decreasing
serum glucose
10. Long-term complications of diabetes include
microangiopathy (retinopathy, nephropathy),
macroangipathy (peripheral vascular disease),
neuropathy, skin problems (cellulites, fungal infections,
boils), periodontal disease
B. Clinical findings
1. Subjective: polydipsia; polyphagia; fatigue; blurred
vision (retinopathy; osmotic changes); peripheral
neuropathy
2. Objective
a. Polyuria; weight loss; glycosuria
b. Peripheral vascular changes; ulcers; gangrene
3. Diagnostic evaluation
a. Blood chemistry shows increase glucose,
potassium, chloride, ketone, cholesterol, and
triglycerides levels; decreased carbon dioxide level;
and pH less than 7.4
b. Fasting blood glucose level is increased (126 mg/dl
or greater)
c. Glycosylated hemoglobin assay (Hb A 1c) is
increased
d. Glucose tolerance test results show hyperglycemia
e. Two-hour postprandial blood glucose level shows
hyperglycemia (greater than 200 mg/dl)
f. Urine chemistry shows increased glucose and
ketone levels
 A less reliable indicator as compared with
blood glucose monitoring
 Instruct the client in the procedure fort testing
urine for glucose and ketones
 Teach the client that the second voided urine
specimen is most accurate
 The presence of ketones may indicate
impending ketoacidosis
 Urine ketone testing should be performed
during illness and whenever the client with type
1 diabetes mellitus has glycosuria pr
persistently elevated blood glucose levels
(greater than 240 mg/dL) for 2 consecutive
testing periods
4. Drug therapy options
 a. Insulin or oral antidiabetic agent: acetohexamide
(Dymelor), chlorpropramide (Diabenese), glipizide
(Glucotrol), glyburide (DiaBeta, Micronase),
tolazamide (Tolinase), tolbutamide (Orinase)
b. Vitamin and mineral supplement
5. DKA and HHKS
a. Hyperglycemia, glycosuria, polyuria
b. Dehydration: flushed, hot, dry skin, decreased skin
turgor (tenting), hypotension, tachycardia, thirst,
headache, confusion, drowsiness
c. Metabolic acidosis (DKA only): Kussmaul
respirations as body attempts to blow off carbon
dioxide; ketonuria, sweet breath odor, anorexia,
nausea, vomiting, decreased serum pH. Decreased
Pco2
6. Hypoglycemia (insulin shock or reaction)
a. Occurs as a result of sympathetic nervous
stimulation or reduced cerebral glucose supply
b. CNS effects: mental confusion, blurred vision,
Diplopia, slurred speech, fatigue, seizures
c. SNS (adrenergic) effects: nervousness, weakness,
pallor, diaphoresis, tremor, tachycardia, hunger
C. Oral hypoglycemic medications
a. Prescribed for clients with diabetes mellitus type 2
b. Assess the client’s knowledge of diabetes mellitus
and the use of oral hypoglycemic agents
c. Assess vital signs and blood glucose levels
d. Assess the medications that the client is currently
taking
e. Aspirin, alcohol, sulfonamides, oral contraceptives,
and monoamine oxidase (MAOIs) increase the
hypoglycemic effect
f. Glucocorticoids, thiazide diuretics, and estrogen
increase blood glucose levels
g. Instruct the client on how to recognize symptoms of
hypoglycemia and hyperglycemia
h. Instruct the client to avoid over-the-counter
medications unless prescribed by the physician
i. Instruct the client not to ingest alcohol with
sulfonylureas
j. Inform the client that insulin may be needed during
stress, surgery, or infection
k. Instruct the client in the necessity of compliance
with the prescribed medication
l. Advise the client to obtain Medic-Alert bracelet
D. Insulin
a. Used in the treatment of type 1 diabetes mellitus
and in type 2 diabetes mellitus when diet and
weight control therapy have failed to maintain
satisfactory blood glucose levels
b. Regular insulin is used in the emergency treatment
of diabetic ketoacidosis
c. Aspirin, alcohol, oral anticoagulants, oral
hypoglycemia, beta-blockers, tricyclic
antidepressants, oral contraceptives, and estrogen
increase blood glucose levels
d. Glucocorticoids, thiazide diuretics, thyroid agents,
oral contraceptives, and estrogen increase blood
glucose levels
e. Illness, infection, and stress increase the need for
insulin should not be withheld during illness,
infection, or stress, because hyperglycemia and
ketoacidosis can result
f. Instruct the client to recognize symptoms of
hypoglycemia and hyperglycemia
g. The peak action time of insulin is very important
because of the possibility of hypoglycemic
reactions occurring during that time
E. Therapeutic interventions
1. Lifestyle changes
a. Weight control: obesity leads to insulin resistance;
this can be reversed by weight loss
b. Exercise: increases insulin sensitivity but must be
regular; brisk walking, swimming, and bicycling are
recommended
c. Diet: current recommendations include:
 Caloric control to maintain ideal body weight
 50% to 60% of caloric intake should be from
carbohydrates, high-fiber foods rich in water-
soluble fiber (oat bran, peas, all forms of beans,
pectin-rich fruits and vegetable); foods with
high glycemic index should be avoided;
glycemic index refers to effect of particular
foods on blood glucose
 Protein: intake should be consistent with the
dietary guidelines, usually between 60 and 85
grams; should be 12% to 20% of daily calories
 Fat intake not to exceed 30% of daily calories
(70 to 90 grams per day); keep saturated fat
intake low; emphasize mono- and polysaturated
fats
 Dietary ratio: carbohydrate to protein to fat
usually about 5:1:2
 Distribute food fairly evenly throughout the
day in 3 to 4 meals, with snacks added between
and at bedtime as needed in accordance with
total food allowance and therapy (insulin or
oral hypoglycemics)
 Basic tools for planning diet: Diabetes Food
guide Pyramid, food composition tables
showing nutrient content and glycemic index of
foods
d. Self-monitoring of blood glucose (SMBG)
 Provides the client with the current blood
glucose level and information to maintain good
glycemic control
 Requires finger prick to obtain a drop of blood
for testing
 Must be used with caution in clients with
diabetic retinopathy and neuropathy
 Instruct the client in the proper procedure for
obtaining the blood glucose level
 Inform the client that the procedure must be
done precisely to obtain accurate results
 Stress the importance of following the
manufacturer’s instructions
 Stress the importance of handwashing before
and after performing the procedure, to prevent
infection
 Instruct the client to calibrate the monitor as
instructed by the manufacturer
 Instruct the client to check the expiration date
on the test strips
 Instruct the client that if the blood glucose
results do not seem reasonable, to reread the
instructions, reassess technique, check the
expiration date of the test strips, and perform
the procedure again to verify results
F. Complications of insulin therapy
1. Local allergic reactions
a. Redness, swelling, tenderness, and induration or a
wheal at the site of injection 1 to 2 hours after
administration
b. Usually occurs during the early stages of insulin
therapy
c. Instruct the client to avoid the use of alcohol to
cleanse the skin prior to injection
d. The physician may prescribe an antihistamine to be
taken 1 hour prior to injection
2. Insulin lipodystrophy
a. Lipoatrophy is loss of subcutaneous fat and appear
as slight dimpling or more serious pitting of
subcutaneous fat; the use of human insulin helps to
prevent this complication
b. Liperhypertrophy is the development of fibrofatty
masses at the injection site and is caused by
repeated use of an injection site
 c. Instruct the client to avoid injecting insulin into
affected sites
d. Instruct the client about the importance of rotating
insulin injection sites
3. Insulin resistance
a. The client taking insulin develops immune
antibodies that bind the insulin, thereby decreasing
the insulin available for use in the body
b. Treatment consists of administering a purer insulin
preparation; occasionally Prednisone is prescribed
to block the production of antibodies
4. Dawn syndrome
a. Results from a nocturnal release of growth
hormone, which may cause the blood glucose to
begin to rise at about 3:00 A.M.
b. Treatment includes administering an evening dose
of intermediate-acting insulin at 10:00 P.M.
5. Somogyi’s phenomenon: insulin-induced hypoglycemia
rebounds to hyperglycemia
a. A rebound phenomenon that occurs during the
initial period of blood glucose control; develops at
peak insulin times and during the night
b. Epinephrine and glucagon are released in response
to hypoglycemia
c. These reactions cause mobilization of the liver’s
stored glucose and Iatrogenic induce hyperglycemia
d. Normal or elevated blood glucose levels are present
at bedtime, a decrease occurs at about 2:00 A.M. to
3:00 A.M. to hypoglycemic levels, and a
subsequent increase occurs as a result of the
production of counter regulatory hormones
e. Treatment includes decreasing the evening
(predinner or bedtime) dose of intermediate-acting
insulin, or increasing the bedtime snack
f. Must be differentiated from the dawn phenomenon,
early morning hyperglycemia attributed to increased
secretion of growth hormone; this requires delaying
administration of PM insulin or increased dosage
6. Insulin waning
a. A progressive rise in the blood glucose level from
bedtime to morning
b. Treatment includes decreasing the evening
predinner or bedtime) dose of intermediate- or long-
acting insulin, or instituting a dose of insulin before
the evening meal if one is not already prescribed
G. Insulin administration: adjusted after considering the client’s
physical and emotional stresses; a specific type of insulin
and schedule is prescribed
a. Insulin pens
 A device that uses a small, prefilled insulin
cartridge that is loaded into a penlike holder; a
disposable needle is attached to the device for
injection
 The client inserts the needle for injection, and
the insulin is delivered by dialing in a dose or
pushing a button for every 1- to 2-unit
increment administered
b. Jet injectors
 A device that delivers insulin through the skin
under pressure in an extremely fine stream
 Insulin administered by this device usually
absorbs faster
 Can cause bruising at the site of insulin
delivery
c. Insulin pump
 Continuous subcutaneous insulin infusion is
administered by an externally worn device
(externally battery-operated) that contains a
syringe attached a long, thin, narrow-lumened
tube with a needle or Teflon catheter attached
to the end
 The administration set is primed and needle
inserted aseptically, usually into subcutaneous
tissue of abdomen
 Small (basal) doses of regular insulin are
programmed into computer to be delivered
every few minutes; bolus doses (extra preset
amounts) are delivered before meals and a
prescribed amount of insulin for 24 hours plus
priming is drawn into syringe
 The client inserts the needle of Teflon catheter
into the subcutaneous tissue (usually on the
abdomen) and secures it with tape or a
transparent dressing; the pump is worn either
on a belt or in a pocket; the needle or Teflon
catheter is changed at least every 3 days
 A continuous basal rate of insulin infuses, and
on the basis of the blood glucose level, the
anticipated food intake, and the activity level, a
client delivers a bolus of insulin before each
meal
 The pump uses Regular insulin (buffered to
prevent the precipitation of insulin crystals
within the catheter); some physicians may
prescribe the use of Lispro insulin
 Improves glucose control for clients with wide
variations in insulin need as a result of irregular
schedules, pregnancy, or growth requirements
d. Implantable insulin delivery
 An insulin pump is implanted in the peritoneal
cavity, where insulin can be absorbed in a more
physiological manner
 Not widely used because mechanical problems
associated with the pump, the catheter, and the
insulin delivery exist
e. Inhalant insulin delivery
 Regular insulin is administered in an inhaler
during inspiration
 A less effective method of administration;
absorption across the nasal mucosa is rapid;
however, only a small amount of insulin is
actually absorbed
f. Pancreas transplants
 The goal of pancreatic transplantation is to halt
or reverse the complications of diabetes
mellitus
 The pancreas is transplanted into the peritoneal
cavity; the exocrine secretions drain into the
urinary bladder
 Performed on a limited number of clients
(mostly clients receiving kidney
transplantations simultaneously)
 Immunosuppressive therapy is prescribed to
prevent and treat rejection
ACUTE COMPLICATIONS OF DIABETES MELLITUS
 Hypoglycemia
 Diabetic ketoacidosis (DKA)
 Hyperglycemic hyperosmolar nonketonic
syndrome (HHNS)
A. Hypoglycemia
1. Description
a. Occurs when the blood glucose level falls to less
than 50 to 60 mg/dL
b. Caused by too much insulin or oral hypoglycemic
agents, too little food, or excessive activity
2. Assessment
a. Mild hypoglycemia: a capillary blood glucose level
of 40 to 60 mg/dL
 Sweating
 Tremor
 Tachycardia
 Palpitations
 Nervousness
 Hunger
b. Moderate hypoglycemia: a capillary blood glucose
level of 20 to 40 mg/dL
 Inability to concentrate
 Headache
 Lightheadedness
  Confusion
 Memory lapses
 Numbness of the lips and tongue
 Slurred speech
 Impaired coordination
 Emotional changes
 Irrational or combative behavior
 Double vision
 Drowsiness
c. Severe hypoglycemia: the client is unconscious or
experiencing seizures
 Disoriented behavior
 Difficulty arousing from sleep
 Loss of consciousness
 Seizures
3. Implementation
a. 10 to 15 g of simple sugar (e.g., glucose tablets, 4 to
6 ounces of juice or soda, hard candy) followed by
complex carbohydrate and protein (e.g., cheese and
crackers)
b. Establish and intravenous line for circulatory access
c. Administration of 50% dextrose solution
d. If unconscious, glucagon injection to stimulate
glycogenolysis
e. Give 10 to 15 g of a fast-acting simple carbohydrate
SIMPLE CARBOHYDRATES TO TREAT
HYPOGLYCEMIA
Three or four commercially prepared glucose tablets
4 to 6 ounces of fruit juice or regular soda
60 to 10 Life Savers or hard candy
2 to 3 teaspoons of sugar or honey
f. Retest the blood glucose level in 15 minutes, and
retreat if it is less than 70 to 75 mg/dL
g. If symptoms persist for more than 15 minutes after
the initial treatment, the treatment is not possible
h. Once symptoms resolve, a snack containing protein
and carbohydrate, such as milk, or cheese and
crackers, is recommended unless the client plans to
eat a regular meal or snack within 30 to 60 minutes
4. Implementation for severe hypoglycemia
a. If the client is unconscious and cannot swallow, an
injection of glucagon is administered either
subcutaneously or intramuscularly
b. After the injection of glucagon, it may take up to 20
minutes for the client to regain consciousness
c. A simple carbohydrate followed by a snack should
be given to prevent recurrence of hypoglycemia
d. In the hospital or emergency department, the client
may be treated with an IV injection of 25 to 50 mL
of 50% dextrose in water
e. The client needs to be instructed to always carry
from some form of fast-acting simple carbohydrate
with him or her
f. If the client has a hypoglycemic reaction and does
not have any of the recommended emergency foods
available, any available food should be eaten; high-
fat foods slow the absorption of glucose, and the
hypoglycemic symptoms may not resolve quickly
g. Family members need to be instructed in the
administration of glucagon
h. The client is instructed if a severe hypoglycemic
reaction occurs, the physician needs to be notified
B. Diabetic ketoacidosis (DKA)
1. Description
a. A life-threatening complication of diabetes mellitus
that develops when a severe insulin deficiency
occur
b. The main clinical manifestations include
hyperglycemia, dehydration and electrolyte loss,
and acidosis
c. The majors causes include a decreased or missed
dose of insulin, illness or infection, and
undiagnosed and untreated diabetes mellitus
2. Assessment: polyuria; polydipsia; blurred vision;
weakness; headache; hypotension; weak, rapid pulse;
anorexia, nausea, vomiting, and abdominal pain; acetone
breath (a fruity odor); Kussmaul’s respirations; mental
status changes
a. Blood glucose levels vary from 300 to 800 mg/dL
b. Low serum bicarbonate and a low pH
c. Sodium and potassium levels may be low, normal,
or high, depending on the amount of water loss and
dehydration status
3. Implementation
 Restore circulating volume and protect against a
cerebral, coronary, or renal hypoperfusion
 Treat dehydration with rapid IV infusions of 0.9%
or 0.45% saline as prescribed; dextrose is added to
IV fluids, such as D5NS or 5% dextrose in 0.45%
saline, when the blood glucose level reaches 250 to
300 mg/dL
 Treat hyperglycemia with IV Regular insulin
administration as prescribed
 Correct electrolyte imbalance (potassium level may
be elevated as a result of dehydration and acidosis,
the serum potassium will decrease and potassium
replacement may be required
4. Insulin administration
a. Use Regular insulin only
b. A dose of 5 to 10 units of regular insulin by IV
bolus may be prescribed before a continuous
infusion is begun
c. Mix the prescribed IV dose of Regular insulin for
continuous infusion on 0.9% or 0.45% saline as
prescribed
d. Flushed the insulin solution through the entire
intravenous infusion set and discard the first 50 mL
of solution prior to connecting and administering to
the client; insulin molecules adhere to the glass and
plastic of IV infusion sets
e. Always place the insulin infusion on an IV infusion
controller
f. Insulin is infused continuously until subcutaneous
administration resumes
g. Monitor vital signs and for signs of fluid overload
h. Monitor potassium levels, glucose levels, and
urinary output, and for signs of increased
intracranial pressure
i. If the blood glucose levels falls too far, too fast
before the brain has time to equilibrate, water is
pulled from the blood to the cerebrospinal fluid and
the brain, causing cerebral edema and increased
intracranial pressure
j. The potassium level will fall rapidly within the first
hour of treatment as the dehydration and the
acidosis are treated
k. Potassium is administered IV as prescribed when
the potassium reaches normal level, to prevent
hypokalemia; ensure adequate renal function before
administering potassium
5. Client education: guidelines During Illness
a. Take insulin or oral antidiabetic medications as
prescribed
b. Test blood glucose and test the urine for ketones
every 3 to 4 hours
c. If the usual meal plan cannot be followed, substitute
soft foods 6 to 8 times a day
d. If vomiting, diarrhea, or fever occurs, consume
liquids every ½ to 1 hour to prevent dehydration
and to provide calories
e. Notify the physician if vomiting, diarrhea, or fever
persist, if blood glucose levels are greater than 250
to 300 mg/dL, when unable to take food or fluids
for a period of 4 hours, or when illness persists for
more than 2 days
C. Hyperglycemia hyperosmolar nonketonic d. Monitor BUN and creatinine levels, and for
syndrome (HHNS) albuminuria
1. Description e. Restrict dietary protein, sodium, and potassium as
a. Extreme hyperglycemia without ketosis and prescribed
acidosis f. Avoid nephrotoxic medications
b. Occurs most often in individuals with type 2 g. Prepare the client for dialysis procedures as
diabetes mellitus prescribed
c. The major difference between HHNS and DKA is h. Prepare the client for kidney transplants as
that ketosis and acidosis do not occur with HHNS prescribed
d. Onset is usually slow and takes hours to days to i. Prepare the client for pancreas transplants as
develop prescribed
2. Assessment
a. Blood glucose level is from 600 to 1200 mg/dL C. Diabetic neuropathy
b. Hypotension 1. Description
c. Dehydration  General deterioration of the nervous system
d. Tachycardia  Complications include foot injuries resulting from
e. Mental status changes trauma and the development of ulcers, frequently
f. Neurological deficits requiring amputation
g. Seizures 2. Assessment
3. Implementation a. Paresthesia
 Similar to the treatment for DKA b. Decreased or absent reflexes
 Includes fluid replacement, correction of electrolyte c. Decreased sensation to vibration or light touch
imbalances, and insulin administration d. Pain, aching, and burning in the lower extremities
 Insulin plays a less critical role in the treatment of e. Poor peripheral pulses
DKA because insulin is not needed for reversal of f. Skin breakdown and signs of infection
acidosis in HHNS g. Weakness or loss of sensation in cranial nerves III,
IV, V, VI
h. Dizziness and postural hypotension
CHRONIC COMPLICATIONS OF DIABETES MELLITUS i. Nausea and vomiting
j. Diarrhea or constipation
A. Diabetic retinopathy k. Incontinence
1. Description l. Dyspareunia
a. A chronic and progressive noninflammatory m. Impotence
impairment of the retinal circulation that eventually n. Hypoglycemic unawareness
causes hemorrhage 3. Implementation
b. Permanents vision changes and blindness can occur a. Early prevention by the control hypertension and
c. The client has difficulty with carrying out the daily blood glucose levels
tasks of blood glucose testing and insulin injections b. Careful foot care to prevent trauma
2. Assessment  Meticulous skin care and proper foot care
a. A change in vision due to ruptured vessels  Inspect feet daily and monitor feet for redness,
b. Blurred vision resulting from macular edema swelling, or break in skin integrity
c. Sudden loss of vision as a result of retinal  Notify the physician if redness or a break in the
detachment skin occurs
d. Cataracts resulting from lens opacity  Avoid thermal injuries from hot water, heating
3. Implementation pads, and baths
a. Maintain safety  Wash feet with warm (not hot) water and dry
b. Early prevention by the control of hypertension and thoroughly (avoid foot soaks)
blood glucose levels  Do not soak feet
c. Photocoagulation (laser therapy) to remove  Do not treat corns, blisters, or ingrown toe nails
hemorrhagic tissue to decrease scarring  Do not cross legs or wear tight garments that
d. Vitrectomy to remove vitreous hemorrhages and may constrict blood flow
thus decrease tension on the retina, preventing  Apply moisturizing lotion to the feet but not
detachment between the toes
e. Cataract removal with lens implant  Prevent moisture from accumulating between
the toes
B. Diabetic nephropathy  Wear loose socks and well-fitting (not tightly)
1. Description: a progressive decrease in kidney function shoes, and instruct the client not to go barefoot
2. Assessment  Change into clean cotton socks daily
a. Microalbuminuria  Wear socks to keep feet warm
b. Thirst  Do not wear same pair of shoes 2 days in a row
c. Fatigue  Do not wear open-toed shoes with a strap that
d. Anemia goes between the toes
e. Weight loss  Check shoes for cracks or tears in the lining
f. Signs of malnutrition and for foreign objects before putting them on
g. Frequent urinary tract infections  Break in new shoes gradually
h. Signs of a Neurogenic bladder  Cut toenails straight across and smooth nails
3. Implementation with an emery board
a. Early prevention by the control of hypertension and  Do not smoke
blood glucose levels c. Apply topical capsaicin (Axsain, Zostrix) for
b. Assess vital signs temporary relief of neuralgia, prescribe
c. Monitor I&O
d. Administer medications as prescribed for pain relief
e. Initiate bladder-training programs
f. Instruct in the use of estrogen-containing lubricants for women with Dyspareunia
g. Prepare the male client with impotence for penile injections or implantable devices as prescribed
h. Prepare for surgical decompression for compression lesions related to the cranial nerves as prescribed
 OPERATIVE CARE FOR THE DIABETIC CLIENT

A. Preoperative care
1. Check with physician regarding withholding oral hypoglycemic medications or insulin
2. Some long-acting oral antidiabetic medications are discontinued 24 to 48 hours prior to surgery
3. Insulin dose may be adjusted or may be withheld if IV insulin administration during surgery is planned
4. Monitor blood glucose level
5. Administer IV fluids as prescribed
B. Postoperative care
1. Administer IV glucose and insulin infusions as prescribed until the client can tolerate oral feedings
2. Administer supplemental short-acting insulin as prescribed, on the basis of blood glucose results
3. Monitor blood glucose levels frequently if the client is receiving total parenteral nutrition
4. When the client is tolerating food, ensure that the client receives an adequate amount of carbohydrates daily to prevent
hypoglycemia and ketosis

Nursing care of Clients with Diabetes Mellitus

A. ASSESSMENT
1. Familial history of diabetes mellitus
2. Cardinal signs of polyuria, polydipsia, polyphagia
3. History of fatigue, visual changes, impaired wound healing, urinary tract infections, fungal infections, and altered sensation
4. Blood glucose levels, hemoglobin A1c
5. Visual acuity and retinal changes
6. Vital signs and weight for baseline data
7. Urine for acetone, microalbumin
8. Renal function and vaginal infection
9. Dietary and exercise patterns

B. ANALYSIS/NURSING DIAGNOSES
1. Ineffective therapeutic regimen management related to complexity of therapies and chronicity of the illness
2. Imbalanced nutrition: less than body requirements related to impaired carbohydrate, fat, and protein metabolism

C. PLANNING/IMPLEMENTATION
1. Assist the client and family to understand the disease process
2. Assess acid-base and fluid balance to monitor for signs of hyperglycemia
3. Monitor for signs of hypoglycemia (vagueness, slow cerebration, dizziness, pallor, tachycardia, diaphoresis, seizures, and coma),
ketoacidosis (acetone breath, dehydration, weak or rapid pulse, Kussmaul’s respirations), and hyperosmolar coma (polyuria, thirst,
neurologic abnormalities, stupor) to ensure early intervention and prevent complications
4. Be prepared to treat hypoglycemia; immediately give carbohydrates in the form of fruit juice, hard candy, or honey. If the client is
unconscious, administer glucagon or dextrose IV to prevent neurologic complications
5. Be prepared to administer IV fluids, insulin and, usually, potassium replacement for ketoacidosis or hyperosmolar coma to reduce
the risk of potentially life-threatening complications
6. Monitor and record vital signs, intake and output, fingersticks for blood glucose, and laboratory studies to assess fluid and
electrolyte balance; monitor wound healing to assess for infection
7. Maintain the client’s diet to prevent complications of diabetes, such as hyperglycemia and hypoglycemia
8. Force fluids to keep the client hydrated
9. Administer medications, as prescribed. Diabetic control requires a dynamic balance between diet, antidiabetic agent, and exercise
10. Encourage the client to express feelings about illness, medication regimen and the necessary changes in lifestyle and self-image to
facilitate coping mechanisms
11. Help the client with the administration of medication until self-administration is both physically and psychologically possible
12. Assist the client in recognizing the need for activities and diet that promote and maintain normal body weight
13. Test urine for ketones when glucose is high; obtain double voided specimen or specimen from port of retention catheter if in place
14. Teach the client and family to:
a. Use blood-glucose-monitoring system to test blood glucose; Test urine for ketones when blood glucose is high
b. Care for the legs, feet, and toenails properly; inspect, bathe, dry; lubricate feet except between toes; avoid exposure of feet to
heat sources; wear shoes to protect feet; avoid infection
c. Administer insulin by using sterile technique, rotating injection sites within an anatomical location, measuring dosage, noting
types, strengths of insulin pump, need t carry carbohydrate source
d. Use Diabetes Food Guide Pyramid and food tables when planning dietary intake
e. Avoid tight shoes and smoking, which will constrict circulation
f. Recognize signs of impending hypoglycemia (insulin shock, reaction) or recognize signs of impending hyperglycemia (DKA,
HHKS)
15. Encourage the client to continue medical supervision and follow-up care, including visits to an eye care specialist and podiatrist
16. Encourage follow-up nutritional counseling

D. EVALUATION/OUTCOMES
1. Complies with medical regimen of diet, exercise, and medications
2. Maintains blood glucose and hemoglobin A1c levels within an acceptable ranges