Diabetes Mellitus

NZ Diploma in Enrolled Nursing

Learning objectives
At the end of this session you will be able to:

• Define diabetes mellitus (DM)

• Identify the risk factors for DM
• Describe the signs of DM
• Identify the complications of DM
• Describe the nursing interventions for the
person with DM in the inpatient setting
You are working in a acute care setting
and Maria asks you
What is diabetes mellitus?

Enrolled Nurses
Diabetes
  is a disease where your body cannot
control its blood sugar levels properly –
either because your body doesn't make
enough (or any) insulin, or because your
cells have become resistant to insulin.

MOH NZ
Diabetes Mellitus definition

A multisystem disease related to:

• abnormal insulin production
• impaired insulin use
• both abnormal insulin production and
impaired insulin use
Diabetes Mellitus

 Insulin is a hormone produced by the

pancreas
 Promotes glucose transport from the
bloodstream across the cell membrane
into the cell for the cell to use for energy
 Normal blood glucose range of 4-7
mmol/L
Maria asks you -

“How does my body keep the blood

glucose level in control?”
Regulation of Blood Glucose
 Factors that increase blood glucose
- a meal
- cortisol
- adrenalin
- glucagon
- growth hormone

 Factors the decrease blood glucose

- insulin/meds
- exercise
- alcohol
Maria then asks you –

“What has caused me to develop

diabetes?” and “are others in my family at
risk”
Risk Factors for Diabetes
 Being overweight or obese
 Hypertension
 High blood cholesterol
(hypercholesterolemia)
 Physical inactivity
 Family history
 > 45 years old
Maria asks
“How does the doctor test me to know that I
have diabetes?”
Diagnosis
 Blood test:
 Non-fasting glucose (≥ 11mmol/L)
 Fasting glucose ≥ 7mmol/L
 Oral Glucose Tolerance Test (OGTT)
 HbA1c glycolated hemoglobin
 Urine:
 glucose in urine (glycosuria) is used to discount
diabetes but the presence of glucose in urine is
not always indicative
Maria asks
“I’ve heard that there are 2 types of diabetes
– what are they?”
Types of Diabetes
Type 1 Type 2
Insulin dependant Insulin resistant
 Complete lack of  Cells become resistant
insulin production by to insulin
pancreas,
consequently no way  Insome cases not
for glucose to get into enough insulin is also
the cells present.

 Autoimmune disorder
Maria is concerned about the signs
of diabetes and asks -
“Apart from feeling tired lately what are the
other signs that I have diabetes?
Signs that a person has
Diabetes Mellitus
 Polyuria – excessive urination
 Polydipsia – excessive thirst
 Fatigue / muscular weakness
 Polyphagia - excessive hunger

Type 2 have the above plus:

 Increased rate of infection
 Visual and sensory changes
 Vaginal candidiasis (thrush)
 Prolonged wound healing
A few days after diagnosis Maria
experiences
 Acute Complications-DKA
Gluconeogenesis
I ncreased Fat Breakdown

Raised Blood Glucose

Ketosis Fruity Breath

Polyuria and dehydration
Ketonuira (fruity urine)

pH < 7.3

Metabolic Acidosis

Raised HR Fatigue Hyperventilation Abdominal Pain

Common Causes( DKA)
 Failure to take insulin
 Infection
 Myocardial infarction
 Pulmonary embolus
 Drugs such as steroids
 New diagnosis

Common Symptoms
 Thirst, polyuria, cramps.
 Nausea, vomiting and abdominal pain common in young patients.
 Weight loss, weakness and drowsiness
 Coma in a small percentage
 Visual disturbance

Signs
 Dehydration
 Tachycardia
 Hypotension
 Hyperventilation
 Hypothermia
Acute Complications:
HHS(Hyperglycaemic
hyperosmolar state)
Drastic worsening of disease

Raised blood glucose > 16mmol

Increased plasma osmolarity

Excessive Polyuria Massive Thirst Severe Potassium

Deficit

Coma / Death
People with diabetes are prone to
complications….
• Cardiovascular disease
• Cerebro vascular accident (CVA)
• Peripheral vascular disease (PVD)
• Retinopathy
• Nephropathy
• Neuropathy
• Infection
• Hyperglycaemia (high blood glucose)
• Hypoglycaemia (low blood glucose)
Nursing Management
Goal: to keep blood glucose levels consistently
within in the normal range
 Type I:
 insulin injections

 Type II:
 diet
 exercise – increases insulin sensitivity of tissues
 regular monitoring of blood glucose levels
 medication eg metformin and / or insulin injections
Medication
 Oral hypoglycaemic agents – 5 groups. All
have different actions.
 Some reduce glucose production by liver
(metformin) or increase insulin production
by the pancreas (glipizide)
 Insulin – Fast (Actrapid)

Medium (Humalog)
Slow acting (Protophane)
Activity
 Increases insulin sensitivity- reducing BGL
 Exercise after meals
 Monitor BGL before and after
 Be aware of signs of hypoglycaemia after
exercise
Diet
 Many people with type 2 are over weight,
aim to reduce
 Healthy eating pyramid
 Plate divided into thirds – 1 third protein, one
third carbohydrate and one third vegetables
 No added sugar, no added salt
 Cholesterol
 Limit alcohol (high in kilojoules)
Foot, skin & dental care
 Peripheral neuropathy and PVD means
that foot care is important
 Cuts & blisters should be treated early
 Susceptible to infections(skin and dental)
Eye health
 Retina checks - retinopathy
 Glaucoma – raised intraocular pressure
What patient education is
required??
Patient education include:
 What diabetes is and all aspects of
diabetes management
 Lifestyle and self-management strategies
 BSL testing, medications
 Diet, exercise, weight management,
smoking cessation
 possible long-term complications, routine
diabetic screening
 Sick day management
 Nursing Management of
Hypoglycaemia (low blood glucose)
 Blood glucose less than 4mmol/L
 Hypoglycaemia may be MILD, MODERATE or SEVERE
 Signs …
 may be asymptomatic (but still needs treatment)

 sweating, nervousness, shaking, palpitations, oral

tingling, hunger
 people with severe hypoglycaemia may have

confusion, reduced concentration, abnormal

behaviour, visual changes, stupor, seizure or coma
 Mild to moderate hypoglycaemia

 BSL <4mmol/L
 Patient conscious and able to swallow
 Administer ONE of the following-
3 glucose tabs; or;
 1 Tbsp jam or honey or sugar; or;
 ½ glass non diabetic lemonade or coke; or;
 ½ glass of fruit juice
 Recheck BGL after 10 mins
 Blood glucose above 4 – give longer acting
carbohydrate such as cheese and
crackers, 2 plain biscuits. Retest after 2
hours
 Blood glucose below 4 – repeat
administration of glucose tabs or
jam/honey or fruit juice.
 Notify medical staff if BGL not above 4 in
30 mins
 Severe hypoglycaemia: a
medical emergency
 If unconscious check airway, put in recovery
position, do not feed
 Ring emergency bell and take BGL
 BGL every 10 mins
 Second nurse specifies medical emergency
 Pt with IV line – 50ml Dextrose
 No IV line – Glucagon 1 mg from resus trolley
(IM)
If Nil By Mouth - GIK Infusion
 G= Glucose
 I = Insulin
 K = Potassium

 Baseline blood glucose level

 2 IV lines inserted– 1 with 10% Dextrose and
potassium, 2nd with insulin (1 unit per ml)
 IV pump is always used
 Blood glucose monitoring – 1hrly
 Insulin dose adjusted as per sliding scale by
Registered Nurse
GIK INFUSION
 Morning theatre list– NBM 0200, no morning diabetes medication,
GIK started at 0700

 PM theatre – NBM 0730, half dose of diabetes medication, GIK

started 1000-1200

 1hourly blood glucose levels. May be done 2 hourly if 3 results are

between 5 -12mmol/L

 GIK until tolerating food and fluids

Follow correct protocol

Gestational Diabetes

 Occurs in non-diabetic pregnant women

 An OGTT in 6th month of pregnancy
 Increased risk of congenital malformation, stillbirth,
large-for-date babies
 Treatment: diet, insulin or both
 50% of women revert back to non-diabetic state but
they have an increased risk of developing type 2
diabetes
References:
 Funnell, R., Koutoukidis, G. & Lawrence,
K. (2009). Tabbner’s Nursing Care (5th
ed.).Sydney, Australia: Churchill
Livingstone