IDENTIFICATION DATA-

Name: Mrs.Kavita Patel

Husband’s name: Mr. Vivek Patel

Age: 50 Yrs.

Sex: Female

Address: Mayur nagar , Vididsha (M.P.)

Religion: Hindu

Marital Status: married

Educational background: 5th standard

Occupation: House wife

Income/month: 10000/month

Date of admission: 24/6/22

I.P.D No.: 13347869

Ward No. : Medical ward 2

Bed No.: bed no 5

Diagnosis: Diabetes Mellitus

Chief Complaints:

The patient, Mrs. Kavita is having complaints of; Chest pain since 2 days, Feeling of
heaviness in chest and sleep disturbance. And also having increased urination, excessive
thirst since 1 month, tingling and numbness in the hands and feet and tiredness much of the
time from 15 days, headache and vision changes.

II. HISTORY

a. Family History

Type of family: Nuclear

Details of the family member:

1
S. Clients position Health If “no” what Duration of What Their present
no in the family Yes/No is the illness the illness treatment condition
taken

1 Mrs. Kavita No DM-type-2 5 Yrs Insulin therapy Hospitalized

2 Mr.Vivek Yes - - -
(husband)

3 Mr. Mohit Yes - - -

(Son)

4. Mrs. Rani Yes - - -

(daughter in –law)

5. Mr.Rahul Yes - - -

Family Tree:
55
50
years
year
Mr Vivek Mrs.Kavita

30
years 26
years

Mr.Mohit Mrs.Rani

5
Mr.Rahul
years
Environmental Sanitation:

 Housing condition: Rental

 Type: Pakka
 Number of Rooms:3 Rooms
 Toilet Facility: Indian
 Electricity facility: Yes Available
 Drinking Water (source): Tape and hand pump

PERSONAL HISTORY:

2
  Hygiene & Grooming: Fair
 Oral hygiene: Fair
Frequency: 1Time in a day
Agent: Colgate
 Dietary habit: Nonvegetarian
 Number of Meals per day: 2-3 /day
 Food preference: Dal , Roti, Vegetables
 Water intak:6-8glasses/Day
 Tea & coffee: No habit of taking tea and coffee
 Bowel habit: Regular
 Bladder Habit: Normal
 Hour of sleep: 6 hrs in night
 Sleep pattern: Interrupted
 Drug used for sleeping, if any (specific) No drugs used
 Rest during day time: 1 hours
 Habits (Smoking & Tobacco chewing):No habits
 Alcohol drinking: No
 Walking habit: No

SOCIOLOGICAL HEALTH

 Relationship with family member/ Peers/Significant/ Others: Good

 Relationship with neighbour: Good
 Economic status perception: Inadequacy of income only her son is earning member

COGNITIVE ABILITIES

 Intellectual comprehensive: Normal

 Learning pattern: abilities present
 Memory: Slight less, Mild forgetfulness
 Concentration: Poor
 Judgement: Present

SPIRITUAL HEALTH

 Faith in God: Yes, in God Sai

 Goes to temple: Yes
 Attitude towards health/disease: Religious

PSYCHOLOGICAL HEALTH

Behaviour: Normal
Facial Expression: Normal
Mannerism: Good
Speech pattern: Normal
Orientation to time, place, person: Yes
Thought process: Altered and she is confused

3
HISTORY OF PRESENT ILLNESS:

As per the history given by patient she experienced chest pain since 2 days. She has feeling of
chest heaviness, vertigo, Ghabrrahat, and sleep disturbance in morning on 24/6/18 at 5.30
AM. Then get admitted in hospital at 9.30 AM. She had history of increased urination, and
excessive thirst since 1 month, tingling and numbness in the hands and feet, tiredness much
of the time from 15 days and also having headache and vision changes.

HISTORY OF PAST ILLNESS:

She is known case of Diabetes Mellitus type-2 from 5 Yrs.

H/O Hypertension from 2 yrs.

No H/O PTB/ fall/ Trauma/ Surgery

PHYSICAL EXAMINATION:
General appearance: Fair
Sense: confused
Vital sign: Temp-98.6 ℉

Pulse-106/min

Respiration-18/min

B.P.-: 130/ 70 mmHg

Height- 4feet ‘9’

Weight- 67 k.g.
Body Posture: Normal
Body built: Endomorphic

HEAD TO FOOT EXAMINATION:

Skin-:

Condition: Dry
Colour: Pink
Temperature: Warm
Turger: Non-elastic
Pigmentation/Lesion/ Scar: There was some redness or rashes present on skin.
Edema: Absent

Nails-:

Clean and dry

4
Head-:

Circumference of the head: 48c.m.

Hair and scalp: Clean
Colour of hair: White
Texture of Hair: Dry
Alopecia: No
Presence of pediculosis: No
Face-:

Expression : Serious
Eyes-:

Appearance: Clean
Ears-: Conjunctiva: pink and moist
Lid: Normal
Cornea: Glossy
Vision: blurred vision

Nose-:
Hearing: Normal
Wax
No Pain

Clean
Any deformity/ Polyp/ Sinus/ Tenderness: No
History of epistaxis: No

Oral Cavity-:

Mouth: Normal
Lips: Dry
Angular stomatitis/ Cleft lip: Absent
Oral Mucosa: Healthy
Tongue: Pink
Throat: Normal
Voice: Normal
Teeth: normally distributed and are sensitive
Gums: Healthy no swelling

Neck-:

Presence of pain: No

5
 Thyroid: Size/ Shape- Normal
Enlargement: Absent
Symmetry: Normal

Neck Vessels-:

Venous distension: Absent

Breast (Female)

Size and shape: normal

Change in colour of areola: Absent
Nipple size: Normal
Discharge from nipple: Absent
Any nodes and lumps: Absent

Respiration System:

Breathing pattern: Normal

Rate: 18/min
Rhythm: Abnormal
Dyspnoea/ Shortness of breath: Present
History of haemoptysis: No

Chest

Size and shape: Normal

Symmetry: Normal
Pain: Present
Crepitation: Absent
Chest movement: Normal

Cardiovascular System:

Pulse rate: Tachycardia

Heart sound: Normal

Gastrointestinal System

Abdomen
 Size and shape: Normal and soft
Abdominal distension- absent
Tenderness and Rigidity- Absent
Bowel sound- Normal
Liver and spleen- Not palpable

6
 Rectum – Normal and No/history of Haemorrhoids/ abscess/ masses/ Lesion/ Itching/
Burning

Neurological System-

Level of conscious- conscious

Mental status- Confused
Alertness- Altered
Orientation to time/ place and person- Oriented
Function of Cranial nerves- Normal
Reflexes- Present

Urinary System-

Urinary output: Polyuria or increased

H/o burning in micturation/ pain- Present

Genitalia-

No history of discharge / swelling/ulceration/ pain

Extremity-

Edema: Absent
Any deformity: Absent

If present then specify

Joint-

Pain/ Discomfort/ stiffness: Present

Musculoskeleton-

Range of motion/ muscles strength not well present

7
 DIABETES MELLITUS TYPE-2

INTRODUCTION- The term "diabetes mellitus" was derived from 2 terms: The Greek word
Diabetes means to Siphon /pass through and the Latin word mellitus means sweet as honey

Diabetes mellitus (DM) is a disease of metabolism characterized by a total or partial

deficiency of the hormone insulin, resulting in a metabolic adjustment or physiologic change
in almost all areas of the body. Diabetes mellitus type-II is chronic progressive disease
characterized by the body’s inability to metabolized carbohydrate, fats, and protein leading to
hyperglycemias.In Diabetes Mellitus there is insulin resistance and impaired Insulin
secretion.

DEFINITION

“Diabetes mellitus is a metabolic disorder characterized by the presence of hyperglycemia

due to defective insulin secretion, defective insulin action or both.”

INCIDENCE

 Diabetes is the third leading cause of death by disease, primarily because of the high rate
of cardiovascular disease (myocardial infarction, stroke, and peripheral vascular disease)
among people with diabetes.
 Approximately 5% to 10% of people with diabetes have type 1 diabetes.
 Approximately 90% to 95% of people with diabetes have type 2 diabetes.
 In the next 10 years, the prevalence of type 2 DM is expected to exceed type 1 in
U.S.children due to obesity, decreased physical activity and overweight.
 By 2030, the number of cases is expected to exceed 30 million. In 2000, the worldwide
estimate of the prevalence of diabetes was 171 million people, and by 2030, this is
expected to increase to more than 360 million (World Health Organization, 2008).
APPLIED ANATOMY

PANCREAS

The pancreas is a pale grey gland weighing about 60 grams. It is about 12 to 15 cm long and
is situated in the epigastric and left hypochondriac regions of the abdominal cavity. It consists
of a broad head, a body and a narrow tail. The head lies in the curve of the duodenum, the
body behind the stomach and the tail towards the spleen. The abdominal aorta and the inferior
vena cava lie behind the gland.

The pancreas is both an exocrine and endocrine gland.

The exocrine pancreas-

This consists of a large number of lobules made up of small alveoli, the walls of which
consist of secretory cells. Each lobule is drained by a tiny duct and these unite eventually to
form the pancreatic duct, which extends the whole length of the gland and opens into the

8
duodenum. Just before entering the duodenum the pancreatic duct joins the common bile duct
to form the hepatopancreatic ampulla.the duodenal opening of the ampulla is controlled by
the hepatopancreatic sphincter (of Oddi).

The endocrine pancreas

Distributed throughout the gland are groups of specialised cells called the pancreatic islets (of
Langerhans) the islets have no ducts so the hormones diffuse directly into the blood.

There are three main types of cells in the pancreatic islets.

 Alpha cells that secretes glucagon

 Beta cells that secrete insulin
 Delta cells that secrete somatostatin
The normal blood glucose level is between 2.5 and 5.3 mmol/litre (45 to
95mg/100ml).

FUNCTIONS (PHYSIOLOGY)

 The function of the exocrine pancreas is to produce pancreatic juice containing enzymes
that digest carbohydrates, proteins and fats.
 The function of the endocrine pancreas is to secrete the hormones insulin and glucagon.

9
INSULIN

The main function of insulin is to reduce blood glucose levels when it rises above
normal.
Insulin promotes storage by:
 Acting on cell membrane and stimulating uptake and use of glucose by muscle and
connective tissue cells
 Glycogenesis
 Decreasing glycogenolysis
 Preventing glyconeogenesis.

GLUCAGON

The effects of glucagon increase blood glucose levels by stimulating, e.g.

 Glycogenolysis
 Gluconeogenesis.

SOMATOSTATIN

The effect of this hormone, also produced by the hypothalamus, is to inhibit the
secretion of both insulin and glucagon.
The normal

BLOOD SUPPLY

The splenic and mesenteric arteries supply arterial blood to the pancreas and the venous
drainage is by the veins of the same names that join other veins to form the portal vein.

NERVE SUPPLY

As in the alimentary tract, parasympathetic stimulation increase the secretion of pancreatic

juice and sympathetic stimulus depress it.

CLASSIFICATION OF DIABETES MELLITUS

Traditionally DM had been classified according to the type of treatment needed. The old
categories were insulin dependence diabetes mellitus (IDDM), or type I, and non-insulin
dependent diabetes mellitus (NIDDM), or typeII.In 1997 these terms were eliminated because
treatment can vary (some people with NIDDM require insulin)and because the terms do not
indicate the underlying problem. The new terms are type1 and type 2, using Arabic symbols
to avoid confusion (e.g., type II could be read as type eleven)

10
1) TYPE 1 DIABETES Formerly known as “juvenile onset” diabetes or insulin-dependent
diabetes (IDDM) Type 1 diabetes is characterized by destruction of the pancreatic beta
cells, which produce insulin; this usually leads to absolute insulin deficiency.
2) TYPE 2 DIABETES MELLITUS is, by far, the most prevalent type of diabetes,
accounting for over 90% of patients with diabetes.
In type 2 diabetes the pancreas usually continues to produce some endogenous (self-
made) insulin. However, the insulin that is produced is either insufficient for the needs of
the body and /or is poorly utilized by the tissues.
3) GESTATIONAL DIABETES 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.

ETIOLOGICAL AND RISK FACTOR OF DIABETES MELLITUS TYPE 2

The development of type 2 diabetes is caused by a combination of lifestyle and genetic

factors.

IN BOOK IN PATIENT

 History of diabetes in parents or siblings. 

 Race/ethnicity: African American, Hispanic, or
-
American Indian origin

 Obesity - A body mass index of greater than 25. Obesity
especially around the waist and abdomen

 Lack of physical activity

 Hypertension

 Increased blood cholesterol (high LDL, low HDL, high

-
triglycerides

 Stress

 \Smoking appears to increase the risk of type 2 diabetes

mellitus

 Dietary factors also influence the risk of developing
type 2 diabetes.
 sugar-sweetened drinks
 saturated fats and trans fatty acids

 Genetics –Genetic mutations that lead to insulin

11
 resistance.
If one identical twin has diabetes, the chance of the other
developing diabetes within his lifetime is greater than 90%,
while the rate for nonidentical siblings is 25–50%.
 Medical conditions -
 Acromegaly
 Cushing's syndrome
 Hyperthyroidism,
 Pheochromocytoma

PATHOPHYSIOLOGY-

The two main problems related to insulin in type 2 diabetes are insulin resistance and
impaired insulin secretion. Insulin resistance refers to a decreased tissue sensitivity to insulin.
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, thus rendering insulin less effective at stimulating glucose uptake by the tissues
and at regulating glucose release by the liver.The exact mechanisms that lead to insulin
resistance and impaired insulin secretion in type 2 diabetes are unknown, although genetic
factors are thought to play a role. To overcome insulin resistance and to prevent the buildup
of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose
level at a normal or slightly elevated level. However, if the beta cells cannot keep up with the
increased demand for insulin, the glucose level rises, and type 2 diabetes develops. Despite
the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin
present to prevent the breakdown of fat and the accompanying production of ketone bodies.
Therefore, DKA does not typically occur in type 2 diabetes. Uncontrolled type 2 diabetes
may, however, lead to another acute problem,

12
 FLOW CHART OF PATHOPHYSIOLOGY

Due to any etiology(family history,obesity,Diet,genetic)

Alteration in the production of hormo

Insulin resistance Inadequate insulin secretion Excess glucose production

Hyperglycemia

Glucoseuria, Polyuria, Polydipsia and polyphagia

Protein and fat are broken down for energy

Diabetic ketoacidosis (rare)

13
CLINICAL MENIFESTATION-

Clinical manifestations of all types of diabetes include the “three Ps”:

IN BOOK IN PATIENT

 Polyuria 
 Polydipsia 
 Polyphagia -
 Fatigue and weakness 
 Sudden vision changes 
 Tingling or numbness in hands or feet 
 Dry skin 
 Skin lesions or wounds that are slow to 
heal, and recurrent infections.
 Headache 
 Hyperglycmias: 
 Elevated blood glucose levels
 Glucoseuria
 Diabetic ketosis: -
 Ketones ,as well as glucose in urine
 Dehydration may or may not be
present
 Diabetic ketoacidosis: -
 Dehydration
 Dry skin
 Electrolyte imbalance
 Drowsiness
 vomiting
 Acidosis
 Deep, rapid breathing(kussmaul)
  Chest pain
 Chest heaviness

DIAGNOSTIC EVALUATION IN BOOK

1) History taking
Obtain a detailed history of family patterns; ask about symptoms like Polyuria, Polydipsia
and polyphagia, the patient may also complain of blurred vision.
2) Physical examination-
Head to toe examination of patient.
3) Random blood sugar test. A blood sample will be taken at a random time and may be
confirmed by repeat testing. Blood glucose values are expressed in milligrams per
decilitre (mg/dL) or millimoles per litre (mmol/L). Regardless of when you last ate, a
random blood sugar level of 200 mg/dL (11.1 mmol /L) or higher suggests diabetes,

14
 especially when coupled with any of the signs and symptoms of diabetes, such as frequent
urination and extreme thirst.
4) Fasting blood sugar test- A blood sample will be taken after an overnight fast (8-12 hrs).
A fasting blood sugar level less than 100 mg/dL (5.6 mmol /L) is normal. A fasting blood
sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/ L) is considered prediabetes. If it's
126 mg/dL (7 mmol/L) or higher on two separate tests, suggests diabetes.
5) Oral glucose tolerance test (OGTT)
 No food or drink 8-12 hours prior to test
 Blood is tested two hours after a 75 g oral glucose load
 Plasma glucose at or above 11.1 mmol/l or (200 mg/dl is almost certain to indicate
diabetes.

6) Glycated haemoglobin (A1C) test

 HbA1c is a test that measures the amount of Glycated haemoglobin in blood. Glycated
haemoglobin is a substance in red blood cells that is formed when blood glucose attach to
haemoglobin.
 This blood test indicates average blood glucose level for the past two to three months. It
measures the percentage of blood sugar attached to the oxygen-carrying protein in red
blood cells (haemoglobin). The higher your blood sugar levels, the more haemoglobin
you'll have with sugar attached.
 Haemoglobin A1C level at or above 48 mmol/mol (≥ 6.5 %) on two separate tests
indicates diabetes.
7) Blood samples periodically to check cholesterol levels, thyroid function, liver function
and kidney function.
8) Urinalysis
 Microalbuminuria
 Glycosuria
 Ketone bodies.

IN PATIENT

1 Blood Examination-:

INVESTIGATION RESULT NORMAL VALUE REMARK

Hb 10.0gm% For female 11-14 Below normal
TLC 8,000/cumm 4000-11000/cumm Normal
Platlets 1.93 lacs 1.5-4.5/ lacs Normal
RBS 350mg/dl 70-140mg/dl Above normal
FBS 200mg/dl 70-110mg /dl Above normal
Urea 35mg/dl 10-50mg/dl Normal
Serum creatinine 1.22mg/dl 0.8-1.6mg/dl Normal
Total Cholestrol 210 - Above normal

15
Urine Examination-:

PARAMETERS RESULT NORMAL VALUE

Colour Turbid pale Yellow Pale yellow
pH Acidic 6.5-7.0
Epithelial cells 8-10 -
Pus cells Nil -
RBC Nil -
Bile Salts Nil -
Ketones Present -

ECG- Tachycardia and shortening of QRS.

MANAGEMENT -

IN GENERAL

The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels
to reduce the development of vascular and neuropathic complications.

There are five components of diabetes management

1. Nutritional management
2. Exercise
3. Monitoring
4. Pharmacologic therapy
5. Education
NUTRITIONAL MANAGEMENT

Nutrition, diet, and weight control are the foundation of diabetes management. The most
important objective in the dietary and nutritional management of diabetes is control of total
caloric intake to attain or maintain a reasonable body weight and control of blood glucose
levels.

Meal Planning and Related Teaching

For all patients with diabetes, the meal plan must consider the patient’s food preferences,
lifestyle, usual eating times, and ethnic and cultural background. For patients using intensive
insulin therapy, there may be greater flexibility in the timing and content of meals by
allowing adjustments in insulin dosage for changes in eating and exercise habits.

Caloric Distribution

A diabetic meal plan also focuses on the percentage of calories to come from carbohydrates,
proteins, and fats. In general, carbohydrate foods have the greatest effect on blood glucose
levels because they are more quickly digested than other foods and are converted into glucose

16
rapidly. Several decades ago it was recommended that diabetic diets contain more calories
from protein and fat foods than from carbohydrates to reduce postprandial increases in blood
glucose levels.

Currently, the ADA and the American Dietetic Association recommend that for all levels of
caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30%
from fat, and the remaining 10% to 20% from protein.

Fibres

 The use of fiber in diabetic diets has received increased attention as researchers study the
effects on diabetes of a high carbohydrate, high-fiber diet.
 This type of diet plays a role in lowering total cholesterol and low-density lipoprotein
cholesterol in the blood.
 Increasing fiber in the diet may also improve blood glucose levels and decrease the need
for exogenous insulin.
 There are two types of dietary fibers: soluble and insoluble. Soluble fiber—in foods such
as legumes, oats, and some fruits— plays more of a role in lowering blood glucose and
lipid levels than does insoluble fiber, although the clinical significance of this effect is
probably small.
 Soluble fiber is thought to be related to the formation of a gel in the GI tract. This gel
slows stomach emptying and the movement of food through the upper digestive tract. The
potential glucose-lowering effect of fiber may be caused by the slower rate of glucose
absorption from foods that contain soluble fiber.
 Insoluble fiber is found in whole-grain breads and cereals and in some vegetables. in the
lists.

Other Dietary Concerns

Alcohol consumption Patients with diabetes do not need to give up alcoholic beverages
entirely, but patients and health care professionals need to be aware of the potential adverse
effects of alcohol specific to diabetes. In general, the same precautions regarding the use of
alcohol by people without diabetes should be applied to patients with diabetes. Moderation is
recommended.

Sweeteners

Using sweeteners is acceptable for patients with diabetes, especially if it assists in overall
dietary adherence. Moderation in the amount of sweetener used is encouraged to avoid
potential adverse effects. There are two main types of sweeteners: nutritive and non-nutritive.
The nutritive sweeteners contain calories, and the non-nutritive sweeteners have few or no
calories in the amounts normally used. Nutritive sweeteners include fructose (fruit sugar),
sorbitol, and xylitol. They are not calorie-free; they provide calories in amounts similar to
those in sucrose.They cause less elevation in blood sugar levels than sucrose and are often
used in “sugar-free” foods. Sweeteners containing sorbitol may have a laxative effect. Non-

17
nutritive sweeteners have minimal or no calories. They are used in food products and are also
available for table use. They produce minimal or no elevation in blood glucose levels and
have been approved by the Food and Drug Administration as safe for people with diabetes.
Saccharin contains no calories

EXERCISE

 Exercise is extremely important in managing diabetes because of its effects on lowering

blood glucose and reducing cardiovascular risk factors.
 Exercise lowers the blood glucose level by increasing the uptake of glucose by body
muscles and by improving insulin utilization.
 It also improves circulation and muscle tone. Resistance (strength) training, such as
weight lifting, can increase lean muscle mass, thereby increasing the resting metabolic
rate. These effects are useful in diabetes in relation to losing weight, easing stress, and
maintaining a feeling of well-being.
 Exercise also alters blood lipid levels, increasing levels of high-density lipoproteins and
decreasing total cholesterol and triglyceride levels. This is especially important to the
person with diabetes because of the increased risk of cardiovascular disease.
 Exercise Precautions Patients who have blood glucose levels exceeding 250 mg/dL (14
mmol/L) and who have ketones in their urine should not begin exercising until the urine
tests negative for ketones and the blood glucose level is closer to normal. Exercising with
elevated blood glucose levels increases the secretion of glucagon, growth hormone, and
catecholamines. The liver then releases more glucose, and the result is an increase in the
blood glucose level.

Exercise Recommendations

 People with diabetes should exercise at the same time (preferably when blood glucose
levels are at their peak) and in the same amount each day.
 Regular daily exercise, rather than sporadic exercise, should be encouraged.
 Exercise recommendations must be altered as necessary for patients with diabetic
complications such as retinopathy, autonomic neuropathy, sensorimotor neuropathy, and
cardiovascular disease.

BLOOD GLUCOSE MONITORING

1. THE GLUCOWATCH BIOGRAPHER uses reverse iontophoresis to draw interstitial

fluid through the skin to measure the glucose level with an electrochemical sensor.
 You can wear the GlucoWatch like a wristwatch. It uses a low electric current to pull
glucose through the skin, so it is minimally invasive. You will be able to program a built-
in alarm to alert you when your glucose level is dangerously low or high.

18
  The GlucoWatch is a major advance in glucose testing. But it doesn't totally replace
conventional meters

2. SELF MONITORING OF BLOOD GLUCOSE WITH GLUCOMETER

 Glucometer is a medical device for determining approximate concentration of glucose in

the blood.
 The device is almost a palm sized one.
 It works on battery so that the device is portable.
 0.3-1 micro litre of blood is enough for the test.
 The test strips contain chemicals that react with the glucose in the blood.
 Result is displayed in mg/dl

COMPONENTS

i. Glucometer
ii. Test strips
iii. Lancet

STEPS

i. Get the requirement in ready condition

ii. Wash hand to prevent infection
iii. Decide where you are getting the blood
 Fingers
 Forearms
 Less sensitive areas
iv. Warm hands for faster flow of blood
v. Fix the strip in the glucometer and when it is ready pierce the finger tip and get a drop of
hanging blood
vi. The results are displayed in approx 40 seconds.
vii. This device is more accurate in figuring the results compared to the lab tests results.

3. Continuous glucose monitoring (CGM) is the newest way to monitor blood sugar levels,
and may be especially helpful for preventing hypoglycaemia.

Continuous glucose monitors attach to the body using a fine needle just under the skin that
checks blood glucose level every few minutes. CGM isn't yet considered as accurate as
standard blood sugar monitoring, so at this time it's still important to check your blood sugar
levels manually.

PHARMACOLOGIC THERAPY

As stated earlier, insulin is secreted by the beta cells of the islets of Langerhans and works to
lower the blood glucose level after meals by facilitating the uptake and utilization of glucose

19
 by muscle, fat, and liver cells. In the absence of adequate insulin, pharmacologic therapy is
essential.

Insulin Therapy and Insulin Preparations

Because the body loses the ability to produce insulin in type 1 diabetes, exogenous insulin
must be administered for life. In type 2 diabetes, insulin may be necessary on a long-term
basis to control glucose levels if diet and oral agents fail. In addition, some patients in whom
type 2 diabetes is usually controlled by diet alone or by diet and an oral agent may require
insulin temporarily during illness, infection, pregnancy, surgery, or some other stressful
event. In many cases, insulin injections are administered two or more times daily to control
the blood glucose level

TIME COURSE OF ACTION -Insulin may be grouped into several categories based on the
onset, peak, and duration of action.

Human insulin preparations have a shorter duration of action than insulin from animal
sources because the presence of animal proteins triggers an immune response that results in
the binding of animal insulin, which slows its availability. Rapid-acting insulin such as
insulin lispro (Humalog) and insulin aspart (Novolog) are blood glucose-lowering agents that
produce a more rapid effect that is of shorter duration than regular insulin.

Categories of Insulin-

Time Agent Onset Peak Duration Indications

courses
Rapid Lispro(Humalog) 10-15 min 1 hr. 3 hrs. Used for rapid reduction
acting Aspart(Novlog) 10-15 min 40-50 min 4-6hrs. of glucose level, to treat
post prandial
hyperglycemia and to
prevent nocturnal
hyperglycemia
Short Regular 1/2 – 1 hr 2-3 hr 4-6hrs Usually administered 20-
Acting (Humalog R, 30min before a meal, may
Novolin R, Iletin be taken alone or in
II Regular) combination with longer
acting insulin.
Intermediate NPH (Neutral 2-4 hr. 6-12hrs. 16-20hrs. Usually taken after food.
acting protamine
hagedorn)
Long-acting Ultralente 6-8h 12-16h 20-30 h Used primarily to control
(“UL”) fasting glucose level
Very long Glargine 1h Continuous 24 h Used for basal dose
acting (Lantus)

20
ALTERNATIVE METHODS OF INSULIN DELIVERY

INSULIN PENS

 These devices use small (150- to 300-unit) prefilled insulin cartridges that are loaded
into a penlike holder.
 A disposable needle is attached to the device for insulin injection. Insulin is delivered
by dialing in a dose or pushing a button for every 1- or 2-unit increment administered.
 People using these devices still need to insert the needle for each injection; however,
they do not need to carry insulin bottles or to draw up insulin before each injection.
 These devices are most useful for patients who need to inject only one type of insulin
at a time (eg, premeal regular insulin three times a day and bedtime NPH insulin) or
who can use the premixed insulins.
 These pens are convenient for those who administer insulin before dinner if eating out
or traveling.
 They are also useful for patients with impaired manual dexterity, vision, or cognitive
function that makes the use of traditional syringes difficult.

JET INJECTORS

 As an alternative to needle injections, jet injection devices deliver insulin through the skin
under pressure in an extremely fine stream.
 These devices are more expensive than other alternative devices mentioned above and
require thorough training and supervision when first used.
 In addition, patients should be cautioned that absorption rates, peak insulin activity, and
insulin levels may be different when changing to a jet injector. (Insulin administered by
jet injector is usually absorbed faster.) Bruising has occurred in some patients with use of
the jet injector.

INSULIN PUMPS

 Continuous subcutaneous insulin infusion involves the use of small, externally worn
devices that closely mimic the functioning of the normal pancreas.
 Insulin pumps contain a 3-mL syringe attached to a long (24- to 42-in), thin, narrow-
lumen tube with a needle or Teflon catheter attached to the end.
 The patient inserts the needle or catheter into the subcutaneous tissue (usually on the
abdomen) and secures it with tape or a transparent dressing.
 The needle or catheter is changed at least every 3 days. The pump is then worn either
on a belt or in a pocket.
 Some women keep the pump tucked into the front or side of the bra or wear it on a
garter belt on the thigh.
 The rapid-acting lispro insulin is used in the insulin pump and is delivered at a basal
rate and as a bolus with meals. A continuous basal rate of insulin is typically 0.5 to
2.0 units/hour, depending on the patient’s needs.
 A bolus dose of insulin is delivered before each meal when the patient activates the
pump (by pushing buttons).

21
  The patient determines the amount of insulin to infuse based on blood glucose levels
and anticipated food intake and activity level.
 Advantages of insulin pumps include increased flexibility in lifestyle (in terms of
timing and amount of meals, exercise, and travel) and, for many patients, improved
blood glucose control.
 A disadvantage of insulin pumps is that unexpected disruptions in the flow of insulin
from the pump may occur if the tubing or needle becomes occluded, if the supply of
insulin runs out, or if the battery is depleted, increasing the risk of DKA.

Complications of Insulin-

Local Allergic reactions

Insulin lipodystrophy
Resistance to injected insulin
Morning hyperglycemia

Oral Antidiabetic Agents

A. First- generation Sulfonylureas

 Acetohexamide(Dymelor)
 Chlorpropamide
 Tolazamide

B. Second- generation Sulfonylureas

 Glipizide(Glucatrol)
 Glyburide
 Glimepiride

(Amaryl) C. Biguanides

 Metformin
 Metformin with Glyburide(Glucovance)

D. Alpha Glucosidase Inhibitors

 Acarbase
 Migilitol(Glycer)

E. Thiazolidinediones

Pioglitazone (Actos)

Rosiglitazone (Avandia)

F.Meglitinides

Repaglinide (Prandin)

22
 Nateglinide (Starix)

TRANSPLANTATION OF PANCREATIC CELLS

Transplantation of the whole pancreas or a segment of the pancreas is being performed on a

limited population (mostly diabetic patients receiving kidney transplantations
simultaneously). One main issue regarding pancreatic transplantation is weighing the risks of
antirejection medications against the advantages of pancreas transplantation.

IN PATIENT

 DIET –
 low fat and low salt
 Soft diet

MEDICATIONS

S.No Name of Action Dose Route Side-effects NSG. Responsibilities

drug
1 S/C  Carbohydrate 10IU S/C Hypoglycemias  Monitor blood
Mixtard metabolism Hs Allergy glucose for
Insulin  Lipid Lipodystrophy hypoglycaemia
metabolism Edema  Observe for
 Protein Allergic reaction
metabolism  Rotate the
injection site
when every dose
administer.
2 Regular  Carbohydrate 20IU S/C Hypoglycemias  Monitor blood
Insulin metabolism Befo Allergy glucose for
 Lipid re Lipodystrophy hypoglycaemia
metabolism each Edema  Observe for
 Protein meal Allergic reaction
metabolism
3 Tab  Reduce 75 Oral Dizziness  Aspirin and other
Aspirin inflammation mg ,nausea, NSAIDs should
by inhibition Vomiting, be given with
of Epigastric food.
prostaglandin distress, peptic  If pt is
synthesis, and ulcer, increased hypertensive,
decrease occult blood in blood pressure
platelet stool, headache, should be
aggregation. confusion, carefully
allergic reactions. checked.
 Sodium intake
should be
restricted.
4 Tab.  Inhibits HMG- 40 Oral GI disturbance,  Assess
Atorvast CoAreductase mg Headache, rashes, hypercholesterole

23
 atin enzyme,which sleep-disturbance mia
reduces  Assess hepatic
cholesterol studies.
synthesis.  Assess bowel
status.
5 Tab.  Inhibits 150 Oral  Headache  assess GI complaints.
Ranitidin histamine at mg  Dizziness  Always taken 30 min
e H2 receptor BD  Diarrohea before food.
site in parietal  hepatotoxi
cells which city
inhibits gastric
acid secretion
6 Tab  Suppress hepatic 500 oral  Nausea,  Nurses should assess
Metform gluconeogenesis mg  Vomiting hypoglycaemic
in  Inhibit glucose  Rarely reactions.
absorption from lactic  Pt. should be told
intestine acidosis about the importance
 Stimulate occurs of maintaining food
peripheral uptake  Headache and drug timing.
of glucose in  Thromboc
tissue in the ytopenia
presence of
insulin

HEALTH EDUCATION

Diabetes mellitus is a chronic illness requiring a lifetime of special self-management

behaviors. Because diet, physical activity, and physical and emotional stress affect diabetic
control, patients must learn to balance a multitude of factors. They must learn daily self-care
skills to prevent acute fluctuations in blood glucose, and they must also incorporate into their
lifestyle many preventive behaviors for avoidance of long-term diabetic complications.
Diabetic patients must become knowledgeable about nutrition, medication effects and side
effects, exercise, disease progression, prevention strategies, blood glucose monitoring
techniques, and medication adjustment.

1. Simple pathophysiology

a. Basic definition of diabetes (having a high blood glucose level)

b. Normal blood glucose ranges and target blood glucose levels

c. Effect of insulin and exercise (decrease glucose)

d. Effect of food and stress, including illness and infections (increase glucose)

e. Basic treatment approaches

2. Treatment modalities

24
a. Administration of insulin and oral antidiabetes medications

b. Diet information (food groups, timing of meals)

c. Monitoring of blood glucose and ketones

3. Recognition, treatment, and prevention of acute complications

a. Hypoglycemia

b. Hyperglycemia

4. Pragmatic information

a. Where to buy and store insulin, syringes, and glucose monitoring supplies

b. When and how to reach the physician For patients with newly diagnosed type 2 diabetes,
emphasis.

5 Skin Care-

To instruct pt. for skin care for the prevention of infection in

diabetes To educate for wound care in the diabetes.
To give proper advices for perineal care after urination for prevention of UTI and vaginal
infection.
To educate for foot care also in diabetes
 Proper bathing, Drying and lubricating feet every day.
 Not to allow moisture between toes.
 Wearing closed-toe shoes that fit her well.
 Kept skin soft and smooth.
 Trim your toenail each week or when needed.
 Kept blood flowing to your feet.
 Protect feet from hot and cold.
 To check with your health care provider. when there is any barefeet, pain and injury.
 Call health care provider if a cut, sore blister or bruise on her foot does not begin to
heal after one day.
 Do not self medicines or use of home remedies for foot.

HEALTH EDUCATION (In my Patient)

 I instruct the patient and her family member about administration of insulin and oral
antidiabetes medications.
 Diet information (food groups, timing of meals)
 Monitoring of blood glucose
 Demonstrate the rotation of sites for the insulin therapy.
 Advice for skin care and foot care in home setting for prevention of injection.
 Educate the patient for physical activity or exercises for management of diabetes and
continuing care of diabetes in home setting.

25
NURSING MANAGEMENT

 Nursing assessment

SUBJECTIVE DATA

History

 Symptoms related to the diagnosis of diabetes:

 Symptoms of hyperglycemia
 Symptoms of hypoglycaemia
 Frequency, timing, severity, and resolution Results of blood glucose monitoring Status,
symptoms, and management of chronic complications of diabetes
 Compliance with prescribed dietary management plan
 Adherence to prescribed exercise regimen
 Compliance with prescribed pharmacologic treatment (insulin or oral antidiabetic agents)
 Use of tobacco, alcohol, and prescribed and over-the-counter medications/drugs Lifestyle,
cultural, psychosocial, and economic factors that may affect diabetes treatment

OBJECTIVE DATA

 Blood pressure (sitting and standing to detect orthostatic changes)

 Body mass index (height and weight)
 Fundoscopic examination
 Foot examination (lesions, signs of infection, pulses)
 Skin examination (lesions and insulin-injection sites)
 Neurologic examination
 Vibratory and sensory examination using monofilament
 Deep tendon reflexes
 Oral examination
 Laboratory Examination

NURSING MANAGEMENT IN PATIENT

NURSING DIAGNOSIS

1. Acute chest pain related to myocardial ischemia as evidenced by severe chest pain
and heaviness in chest.
2. Imbalanced nutrition more than body requirements related to intake in excess of
activity expenditure as evidenced by hyperglycemia.
3. Ineffective therapeutic regimen management related to insufficient knowledge as
evidenced by inaccurate statements regarding diabetes and its treatment.
4. Risk for injury related to decreased tactile sensation, episodes of hypoglycemia
5. Risk for impaired skin integrity related to hyperglycemia, peripheral sensory
neuropathy, motor function deficit.

26
 NURSING CARE PLAN

1.ASSESSMENT

Subjective data

Patient told that she is having chest pain and heaviness in chest

Objective data

I observed that patient is having acute chest pain which aggravated by activities.

NURSING DIAGNOSIS- Acute chest pain related to myocardial ischemia as evidenced by

severe chest pain and heaviness in chest.

EXPECTED OUTCOME- Reports relief of pain

S. PLANNING NURSING RATIONALE EVALUA

NO INTERVENTION TION
1.  Evaluate chest  Evaluated chest pain, she is  To Patient reported
pain ,intensity, having pain in substernal accurately relief of pain.
location, region which is aggravated evaluate,
radiation, by activities. treat, and
 duration and prevent
precipitating and further
alleviating ischemia.
factors
 Provide  Provided comfortable  To reduce
comfortable position to the patient that pain.
position to the is semi fowler’s position
patient
 Obtain 12-lead  Obtained 12-lead ECG  To know the
ECG during pain during pain episode that cause of
episode. revealed tachycardia pain
and shortening of QRS.
 To increase
 Administer  Administered oxygen via
oxygenation
oxygen therapy face mask 5litre/min. of
myocardial
tissue

 Administer  Administered medication  To relieve

medication as as prescribed by physician pain.
prescribed by that is aspirin 75 mg.
physician.

27
 2. ASSESSMENT

Subjective data

Patient told that she is having excessive thirst, urination and hunger, weakness, lethargy,
blurring of vision and headache.

Objective data

I observed that patient is having sign of hyperglycaemia and increased cholesterol level.

NURSING DIAGNOSIS

Imbalanced nutrition more than body requirements related to intake in excess of activity
expenditure as evidenced by hyperglycaemia.

EXPECTED OUTCOME

Maintains a balance of nutrition, activity and insulin availability.

S PLANNING NURSING INTERVENTION RATIONALE EVALUA

. TION
N
O
2  Assess the  Assessed the nutritional status of  To provide Now
. nutritional status of patient baseline data patient’s
patient blood glucose
 To alert patient level is
 Monitor for signs  Monitored for signs and to glucose decreased as
and symptoms of symptoms of hyperglycemia: she imbalance and compared to
hyperglycemia. is having polyuria, polydipsia, need for previous and
Polyphagia, weakness, lethargy, treatment. she is not
blurring of vision and headache. having
 Assist the patient  To improve headache,
to accommodate  Assisted the patient to compliance weakness,
food preferences accommodate food and lethargy.
into the preferences into the prescribed
prescribed diet diet.
 Facilitate  To promote
adherence to diet  Facilitated the patient for diabetes control.
and exercise adherence to diet and  To decrease the
regimen exercise regimen. body’s
 Restrict exercise requirement.
when blood glucose  Restricted exercise when  To control
levels are more patient’s blood glucose levels are weight gain
than 250mg/dl. more than 250mg/dl.  To know the
 Check the weight of laboratory values
the patient.  Check the weight of the patient. of patient and
 Monitor serum Her weight is 67 kg compare it with
laboratory .Monitored serum laboratory values. normal values.
values Her cholesterol level is 210 mg/dl

28
 3. ASSESSMENT

Subjective data

Patient told that she is not having knowledge about her disease, treatment and diet.

Objective data

I observed that patient is having

Many doubts regarding her disease, treatment, and diet. She repeatedly asks the questions.

NURSING DIAGNOSIS

Ineffective therapeutic regimen management related to insufficient knowledge as evidenced

by inaccurate statements regarding diabetes and its treatment.

EXPECTED OUTCOME- Verbalizes key elements of the therapeutic regimen

S. PLANNING NURSING RATIONALE EVALUA

NO INTERVENTION TION
3.  Assess the  Assessed the knowledge  To Patient
knowledge level level of patient, she have determine verbalized key
of patient. many doubts regarding her the scope elements of the
disease, treatment, and diet. and extend therapeutic
of required regimen including
 Provide  Provided information teaching. knowledge of
information regarding the  To enable disease and
regarding disease pathophysiology of patient to treatment plan.
process. diabetes and the function better
and actions of insulin in understand
relation to caloric intake rationale
and exercise behind
treatment
 Answer  Answered questions and regimen.
questions and clarify misconceptions of  To ensure
clarify patient regarding diabetes, optimal
misconceptions and its diet. learning
to ensure optimal
learning
 Explain the  Explained the function and  Because
function and expected effects of these are a
expected effects procedures and tests. necessary
of procedures part of
and tests, diabetes
manageme
nt

29
 ASSESSMENT

4. Subjective data

Patient told that she is having blurred vision, headache and numbness in hands and feet.

Objective data

I observed that patient is having sign of decreased tactile sensation, and sometime episodes of
hypoglycaemia.

NURSING DIAGNOSIS

Risk for injury related to decreased tactile sensation, episodes of hypoglycaemia

EXPECTED OUTCOME –

Experience no injury resulting from hypoglycaemia and decreased sensation in feet

S. PLANNING NURSING INTERVENTION RATIONALE EVALUA

N TION
O
4.  Provide information  Provided information regarding  To promote Patient
regarding the the relationship between commitment to reported that
relationship between neuropathy, injury, and risk for care. now she is
neuropathy, injury, ulceration. comfortable
and risk for ulceration. and reduce
 Monitor for signs and risk of
symptoms of Hypoglycemia
hypoglycemia .
 Monitored for signs and  To alert patient to
symptoms of hypoglycaemia. She glucose imbalance
is having blurred vision and and need for
 Determine patient’s treatment.
headache.
recognition of  To assess learning
hypoglycaemia sign needs.
and symptoms.  Determined patient’s recognition
 Instruct patient to have of hypoglycaemia sign and
simple carbohydrate symptoms.  To treat
available at all times hypoglycaemia-
 Instruct patient to mia.
obtain and carry  Instructed patient to have simple
appropriate emergency carbohydrate available at all
identification times, she keep candy with her.  To facilitate
treatment by
 Instructed patient to obtain and others
carry appropriate emergency
identification
5. ASSESSMENT

Subjective data

Patient told that she is having tingling and numbness in her hands and feet

30
 Objective data

I observed that she is having decreased sensory perception in her feet.

NURSING DIAGNOSIS -Risk for impaired skin integrity related to hyperglycaemia,

peripheral sensory neuropathy, motor function deficit.

EXPECTED OUTCOME - Maintain skin integrity

S PLANNING NURSING INTERVENTION RATIONALE EVALUA

. TION
N
O
5  Assess the general  Assessed the general appearance  To provide Patient told
. appearance of the of the foot. Her skin is very dry baseline data that she
foot. Note and foot hygiene is poor. implements
hygiene. all measures
 Assess skin integrity.  Assessed skin integrity. Her skin  To establish to maintain
Note colour of skin, is dry, cracked, pale colour and baseline her skin
presence or absence findings. integrity.
ulceration is absent
of ulceration,
moisture, quality of
the skin, and
presence of  Instructed the patient about
dermatitis. principles of hygiene-wash feet
 Instruct the daily in warm water using mild
patient about
soap.dry carefully and gently,  To prevent
principles of infection
hygiene especially between the toes.

 I taught the patient to inspect feet

daily for cuts, scratches, and
 Teach the patient to blisters
inspect feet daily.  To prevent
 Instructed the patient to report conditions that
signs of infection immediately to favour skin
the primary care provider. breakdown.
 Instruct patient to
report signs of
infection immediately  Instructed patients to always wear
to the primary care  To prevent
protective footwear; never go
complications
provider. barefoot
 Instruct patients to
always wear  To prevent skin
protective footwear;  Instructed patient to maintain breakdown
never go barefoot. adequate hydration. She takes 8-
 Instruct patient to 10 glass of water per day.
maintain  To decrease
adequate blood viscosity
hydration

31
3
3
3
3
3
APPLICATION OF THEORY

In my patient Orem’s theory of self care deficit is applicable as after admission

my patient requiring assistance to achieve health and independent ability to
perform activities of daily living. I assist and support the patient in daily
activities and the attainment of independence
COMPLICATION-

Acute complication-

 Hypoglycemia
 Diabetic Ketoacidosis
 Hyperglycemia

2 Long term complication

Macrovascular complication

 Coronary artery disease

 Cerebrovascular disease
 Peripheral vascular disease.

Microvascular complication

1. Diabetic Retinopathy
2. Nephropathy
3. Diabetic Neuropathies
4. Complications of feet and lower extremities.
5. Infections

IN PATIENT:

 Hypoglycemia
 Diabetic Ketoacidosis
 Hyperglycemia
 Coronary artery disease

PROGNOSIS IN GENERAL

Diabetes increases the likelihood of major cardiovascular events and death, but the increased
risk is variable across patients depending on age at diabetes onset, duration of diabetes,
glucose control, blood pressure control, lipid control, tobacco control, renal function,
microvascular complication status, and other factors. When type 2 diabetes is diagnosed at
age 40, men lose an average of 5.8 years of life, and women lose an average of 6.8 years of
life. The overall excess mortality in those with type 2 diabetes is around 15% higher, but
ranges from ≥60% higher in younger adults with poor glucose control and impaired renal

3
function, to better than those without diabetes for those who are age 65 and over with good
glucose control and no renal impairment.
Effective treatment requires a motivated and informed patient who actively takes
responsibility for the care of his or her diabetes, and a health care provider team willing to
frequently adjust medications to support comprehensive disease management over a long
period of time.

PROGNOSIS IN PATIENT
Mrs. Kavita was admitted with the complain of chest pain and heaviness in the chest, after
investigation, proper treatment and nursing care she maintained blood glucose level, vital
signs ,normal weight and have normal dietary pattern. Her prognosis is good.

CONCLUSION

Diabetes mellitus (DM) is a disease of metabolism characterized by a total or partial

deficiency of the hormone insulin, resulting in a metabolic adjustment or physiologic change
in almost all areas of the body. Diabetes mellitus type-II is chronic progressive disease
characterized by the body’s inability to metabolized carbohydrate, fats, and protein leading to
hyperglycaemias. In Diabetes Mellitus there is insulin resistance and impaired Insulin
secretion. The main goal of diabetes treatment is to normalize insulin activity and blood
glucose levels to reduce the development of vascular and neuropathic complications.

There are five components of diabetes management -

Nutritional management, Exercise, Monitoring, Pharmacologic therapy and Education

3
 BIBLIOGRAPHY
 Black, J.M. (2009), Medical Surgical Nursing, 8th Ed, Saunders Elsevier ,New Delhi
1021-1040
 Lemone Burke. (2008) Medical Surgical Nursing, 4th Ed, South Asia. Dorling Kindersley
(India)Pvt .Ltd,1597-1606
 Lewis. (2011) ,Medical Surgical Nursing,6th Ed, Elsevier India,1243-1274
 Luckmann.J.(1997),Saunders Manual of Nursing care,1st edition, W.B Saunders
Company USA, 1230-1259
 Nettina.M.S.(2011),Lippincott manual of Nursing Practice,8th Ed, Wolters Kluwer India
Pvt Ltd New Delhi,850-880
 Phipp’s. (2009), Medical Surgical Nursing Health and Illness Perspective 8th Ed,
Elsevier, a division of reed Elsevier India Pvt Ltd ,1590-1595
 Ross and Wilson.(2006), Anatomy of physiology 10th Ed, , Anne Waugh of Allison Gant,
New Delhi , 306-307
 Suddarths and Brunner. (2011),Textbook of Medical Surgical Nursing,12th Ed,Wolter
Kluwer Pvt Ltd New Delhi,1149-1198
 www.wikipedia.com
 www.pubmed.com
 www.medinet.com

4
 ADAVANCE NURSING
CARE PLAN
ON
DIABETES MELLITUS

SUBMITTED TO: SUBMITTED BY:

Mrs. ASHA RAM Ms. NARGIS KHAN

M.Sc. Nursing Previous
Govt. College of Nursing

Govt. College of Nursing

4