Diabetes

Mellitus
Margaret Cifuni MSN, RN
Lewis CH 48
ATI CH 82 & 83
 Unit Objectives:
1. Recognize components of a focused assessment that should
be included when collecting data on adults who have an
alteration in regulation and metabolism.
2. Apply knowledge of anatomy, physiology, pathophysiology,
nutrition, and developmental variations when helping to plan
care for adults who have an alteration in regulation and
metabolism.
Alterations in Regulation
and Metabolism (Program 3. Identify priority actions for adults who have an alteration in
Concept: Patient-centered regulation and metabolism.
care, Safety) • NCLEX 4. Apply knowledge of the actions, potential side effects, and
Category: Physiological nursing implications when administering medications to adults
Adaptation, Reduction of who have an alteration in regulation and metabolism.
Risk Potential 5. Recognize alterations in laboratory values related to
alterations in regulation and metabolism.
6. Discuss the correct use and functioning of therapeutic
devices that support regulation and metabolism.
7. Describe the role of the nurse in providing quality care to
adults who have an alteration in regulation and metabolism.
8. Identify health care education and safety needs for adults
who have an alteration in regulation and metabolism.
Student Learning Outcomes

1. Describe the pathophysiology and clinical manifestations of

diabetes mellitus.
2. Differentiate between type 1 and type 2 diabetes mellitus.
3. Describe the interprofessional care of a client with diabetes
mellitus.
4. Describe the role of nutrition and exercise in the management
of diabetes mellitus.
5. Differentiate between the various categories of insulin including
onset, peak, and duration.
6. Discuss the acute and chronic complications of diabetes
mellitus.
7. Describe patient teaching in relation to blood glucose
monitoring, drug therapy, nutrition, exercise and foot care.
 • Diabetes Mellitus
• Patho
• 4 Classifications
• Risk Factors
• Hyper & Hypoglycemia
• Clinical manifestations
• Causes
Lecture • Treatment
• Diagnostic Criteria
Outline • Client Centered Care
• Medications
• Nutrition
• Exercise
• Client teaching
• Acute Complications
• DKA
• HHS
• Chronic Complications
 • During a BHCC student nurse’s clinical
shift, the student nurse is assigned to
BHCC R.H, a 62-year-old female complaining
Student Nurse of fatigue, an increasing need for
Vignette water, and the need to urinate
frequently. The BHCC student nurse
notes a fingerstick=285 mg/dL,
temp=98.8 F.
 • Metabolic Disorder
• Disorder of glucose
metabolism related to absent,
Diabetes insufficient, or poor use of
Mellitus insulin
• Insulin is the problem in DM
(DM) • Affects nearly 25.8 million
people in the United States
• More prevalent in African
Americans, Native Americans
& Hispanics
Insulin

• Hormone
• Released into blood
stream to maintain
normal glucose levels
• Facilitates glucose
entry into the cell.
• Cells break down
glucose to make
energy
• Liver & muscle cells
store excess glucose
Class Activity
4 Classifications of Diabetes

• Type 1 DM

• Type 2 DM

• Prediabetes

• Gestational Diabetes
Type 1 DM

• Acute Onset before age

30

• Pancreatic Beta cells are

destroyed

• Produce no insulin

• Insulin dependent for life

• “Type 1 pt. has NONE”

Type 2 DM

• Gradual Onset after age 30

• Pancreas continues to
produce some insulin
(inadequate insulin
production)
• Or body does not use
insulin effectively (insulin
resistance)
• Increasing in children
• Treated initially with diet
and exercise then oral
hypoglycemics then insulin
• “Type 2 Cells are
through”
 Type 2

Risk Factors • Family History of diabetes

• Poor Diet

Type 1 • Obesity (BMI >25)

• Sedentary Lifestyle
•Genetic
predisposition • Hypertension

• Greater prevalence in ethnic groups

•Immunologic or
• Waist size 35+ females
environmental (viral 45+ males
or toxins) factors
 Hyperglycemia
Signs & Symptoms Causes

Glucose >250mg/dL • 4 S’s

“3 Polys” • Sepsis (infection)
• Polyuria • Stress (surgery)
• Polydipsia
• Polyphagia • Skip Insulin
Fatigue & weakness • Steroids (prednisone)

Sudden vision changes

Slow healing wounds Treatment

INSULIN
Recurrent infections

Type 1 weight loss

 Hypoglycemia
Signs & symptoms Causes
Glucose <70mg/dL
• Exercise
Diaphoresis/Clammy
• Alcohol (lowers sugar)
Pallor
• Insulin Peak times (lowers
Dizziness sugar)
Confusion
Headache
Hunger
Treatment
Sleepiness
GIVE SUGAR
• Awake/Ask to eat
Lack of coordination
• Sleepy not alert
Slurred speech unarousable/Give
Severe hypoglycemia: disorientation, dextrose IV
tremors, death
Class Activity
 1. Random blood glucose > 200mg/dL
(normal 70-110mg/dL)
2. Fasting blood glucose >126 mg/dL
(normal 70-105 mg/dL)
Diagnosti 3. Oral glucose tolerance test (OGTT) >200mg/dL
c Criteria (normal under 140)
4. Glycosylated hemoglobin HgbA1c or A1c> 6.5%
(normal 4-5.6%)
Used to diagnose, monitor response to therapy
5. Ketones accumulate in blood due to breakdown of
fatty acids when insulin not available
6. High ketones in urine associated with
hyperglycemia exceeds 300
Class Activity
 Case Study
R.H., 62-year-old woman, comes to the clinic for a routine physical
examination.
• Works as a banking executive and gets little
exercise.
• States “just tired.”
• BP is 162/98, heart rate is 92, and respiration
rate is 20.
• Complains of some weakness/numbness in
her right foot that began about a month ago.
• Complains of increased thirst and frequent
nighttime urination
 1. What risk factors for diabetes
does R.H. have?

Case 2. Which type of diabetes is R.H. at

highest risk for developing?

Study
Questions 3. What clinical manifestations of
diabetes is she displaying?

4. What diagnostic tests for

diabetes would the nurse expect
the health care provider to
order?
 Patient-Centered Care

• Monitor Blood Glucose

• Admin meds
• Provide education
• Nutrition Therapy
• Monitor For complication
• Exercise
 • Monitor 4 or more times a day
• When to test
• Before meals
• Two hours after meals
• When
hypoglycemia/hyperglyce
Monitorin mia is suspected
g • During illness
• Before, during, and after
Blood exercise

Glucose
Medications
Insulin Therapy

• 4 Categories of insulin
• Rapid acting
• Short acting
• Intermediate acting
• Long acting

• Given 1 or more times a day

Rapid Acting Insulin
• Ex: Lispro, Aspart, Glulisine
• Fastest peak & onset most deadly
• Onset is rapid, 15-30 min depending
on which insulin is administered
• Client must be eating or having food
within 10-15 mins

• Inhaled insulin (Afrezza) rapid acting

Short Acting Insulin
• Ex: Regular

• Administer 30-60 min before meals

to control postprandial
hyperglycemia

• Can be administered SC or IV
Intermediate Acting Insulin
• Ex: NPH
• Contains protamine (a protein), causes a
delay in the insulin absorption or onset and
extends the duration of action of the insulin
• Administer SC only
• Only insulin to mix with short-acting
• Cloudy in appearance gently rotate before
administration
Long Acting Insulin

• Ex: Glargine, Detemir

• Administered once daily
• Duration 24 hours
• No Peaks
• No Mix
• Administer SC only and never IV
 Onset Peak Duration

Rapid-acting: 10-30 min 30 min-3 hr 3-5 hr

Lispro

Short-acting: Regular 0.5-1 hr 1-5 hr 6-10 hr

Intermediate: 1-2 hr 6-14 hr 16-24 hr

NPH

Long-acting: glargine 70 mins None 24 hr

Insulin
Delivery
Devices
Transient Hyperglycemia
 Bolus dose for meals
External device
which is calculated by
Insulin Pump provides basal dose of
rapid acting or regular
client using a
predetermined insulin
insulin
to carbohydrate ratio

Continuous infusion of Enter in carbohydrates

insulin & blood glucose levels

Needle inserted into SC Change needle every 3

abdominal tissue. days

Allows for flexibility in

diet
Class Activity
 Decrease blood glucose and makes
body more sensitive to insulin

Used after diet and exercise isn’t

Oral working in type 2
Hypoglycemi
c Medications Combinations of oral drugs may be
used

Nursing interventions: monitor

blood glucose for hypoglycemia and
other potential side effects
 Metformin

Actions
• Reduce glucose production by liver

Nursing considerations
• Monitor significance of GI effects
Biguanides • Stop 48 hrs prior to and 48 hrs after a
test with IV contrast dye

Client education
• Take with food to decrease GI upset
• Take vitamin B12 and folic acid
supplements
• Never crush or chew
 “ ides, rides, mides, zides “

Examples: Glipizide, Glimepiride, Glyburide,

Glynase

Actions
• Simulates insulin release from the pancreas causing a
Sulfonylureas decrease in blood sugar levels

Nursing Considerations
• Monitor for hypoglycemia

Client Education
• Administer 30 minutes before meals
• Monitor for hypoglycemia and report frequent episodes
• Avoid alcohol due to disulfiram effect
 Alpha-glucosidase inhibitors: acarbose,
miglitol
• AKA starch blockers
• Slows carb absorption and digestion

Gliptins: sitagliptin
• Promotes release of insulin, lowers glucagon secretion
More Oral and slows gastric emptying
Hypoglycemic
s Meds Meglitinides: repaglinide, nateglinide
• Stimulates insulin release from the pancreas
• Admin 15-30 mins prior to meal must eat within 30 mins

Thiazolidinediones: rosiglitazone, pioglitazone

• Reduces glucose production by liver
• High risk of CHF d/t fluid retention
 • “Rule of 15”
• Give 15 g of fast-acting carbohydrates
• 3 or 4 glucose tablets
• 4 oz of juice or regular soda
• 2or3 tsp of sugar or honey
• Wait 15 mins
Management • Recheck blood glucose if <70 mg/dL give 15g
of more carbo’s
• Recheck bld glucose in 15 mins
Hypoglycemi • Do 2 or 3 doses
a • When Blood glucose in nL range give 7g of protein
• 2Tbsp peanut butter
• 1 oz cheese
• 8 oz milk
 • If the patient cannot swallow or
is unconscious:
• Admin Subcutaneous or
intramuscular glucagon (1
Emergency mg)
Measures • 25 to 50 mL of 50% dextrose
solution IV
• Notify provider
 Management of Hyperglycemia

Teach
• client the clinical manifestations of hyperglycemia
Encourage
• oral intake of sugar-free fluids to prevent dehydration
• client to wear a medical identification wristband
Administer
• insulin as prescribed
Restrict
• exercise when blood glucose levels are greater than 250 mg/dL
Test
• urine for ketones
 Hot and dry-blood sugar high
if the diabetic’s skin is hot and is
dehydrated, blood glucose level
is likely high.

Red and hot, need a shot

Mnemonic the skin might be red and hot to
touch if the blood glucose level is
extremely high.
Cold & clammy-need some
candy
if the diabetic’s skin is cold and
clammy, the blood glucose level
is low and needs a glucose
source.
 Nutrition Education
Diet Low calories & low in simple carbs

Consult Dietician for collaborative education

Meals to achieve appropriate timing of food intake, activity, onset,

Plan
and peak of insulin.

Eat Regular intervals, and do not skip meals

Fiber in the diet to increase carbohydrate metabolism and to help

Include
control cholesterol levels

Follow American Diabetic Association Diet (ADA)

Alcohol -inhibits breakdown of glycogen into glucose by the liver

Avoid Can cause severe hypoglycemia if pt. on insulin/oral hypoglycemic
meds
Exercise

Lowers blood sugar

Aids in weight loss

Lowers cardiovascular risk

Always check blood sugar before exercising < 100 eat small carb snack
and carry simple carbs while exercising to prevent hypoglycemia

If blood glucose >250 with ketones present in urine avoid exercise

until both stabilize
Class Activity
 Case Study
R.H.’s diagnostic testing results
• Random glucose test: 253 mg/dL
• A1c: 9.1%
• Urine: positive for glucose and negative for protein
R.H. is diagnosis
• type 2 diabetes mellitus.
Orders include
• metformin 500 mg PO bid.
5. What 3 treatment modalities will the nurse expect to teach R.H.
about?

6. What is the mechanism of action of metformin?

7. What would the nurse teach R.H. about metformin?

Client Teaching
Foot care

• Inspect feet daily esp between toes

• Cleanse feet daily in warm soapy water; rinse; pat dry
• Consult a podiatrist
• Proper footwear-supportive & protective
• Avoidance of foot injury
• Skin and nail care
• Trim nails straight across
• Prompt treatment of small problems

Diligent wound care for foot ulcers

Do not go barefoot
 Sick Day Guidelines
• Take usual dose of insulin or oral hypoglycemic agents
• Test blood glucose & urine for ketones every 3-4 hours
• Consume 4 oz. of sugar-free, noncaffeinated liquid every 30 minutes to prevent dehydration
• Eat small frequent meals or soft food (custard, cream soup, gelatin, graham crackers) to meet
carbohydrate needs
• Rest
• Contact provider if:
• Blood glucose is greater than 240 mg/dL.
• Fever is greater than 38.6°C (101.5°F), does not respond to acetaminophen, or lasts more than
24 hrs
• Feeling disoriented or confused
• Experiencing rapid breathing
• Vomiting occurs more than once
• Diarrhea occurs more than 5 times or for longer than 24 hrs
• Unable to tolerate liquids
•
Acute Complications of Diabetes

• DKA

• Hyperglycemic hyperosmolar syndrome (HHS)

• Hypoglycemia
 Diabetic Ketoacidosis (DKA)

Acute
Life threatening
Complication of DM due to insufficient insulin
Bld glucose between 300-800mg/dL
Contributing Factors
• Decreased or missed dose of insulin
• Illness/infection
Clinical features
• Hyperglycemia
• Dehydration
• Acidosis
• Type 1 DM
 Prevention
• “Sick day rules

Clinical Manifestations
• 3 P’s
DKA •
•
rapid weak pulse
Metabolic acidosis & ketonuria
• Acetone breath
• Kussmaul respirations
• Altered mental status: alert,
lethargic, or comatose
• Orthostatic hypotension
 Monitor blood
glucose levels –
usually admitted
Monitor LOC ,VS
between 300 and
800, but can exceed
1000mg.
Nursing
Interventions
DKA Strict I & O Admin IV fluids (NS)

Admin Regular Monitor K+ levels

Insulin IV replace if needed
Hyperglycemic Hyperosmolar
Syndrome (HHS)
Acute

Life threatening

Complication of DM (type 2)

Elevated bld glucose >600 mg/dL

Contributing factors

• Illness
• Meds that exacerbates hyperglycemia esp thiazide
• Clinical Manifestations
• signs of dehydration
• elevated BUN
• Altered mental staus
• No ketosis
 Replace fluids

Monitor Blood glucose

Treatment Insulin administration

of HHS Monitor fluid volume and electrolyte

status

Prevention
• SMBG
• Diagnosis and management of diabetes
• Assess and promote self-care management skills
 Characteristics DKA HHS

Patients affected Type 1 or 2, more common Type 1 or 2, more common

type 1 type 2 and older
Precipitating event Omission of insulin, Physiologic stress (infection,
physiologic stress (infection, surgery, CVA, MI)
surgery, CVA, MI)
Onset Rapid (<24 hours) Slower (several days)
BG levels Usually >250 mg/dL Usually >600 mg/dL
Arterial pH < 7.3 Normal
Serum and urine ketones Present Absent
Serum osmolality 300-350 mOsm/L >350 mOsm/L
Plasma bicarbonate < 15 mEq/L Normal

BUN/creat Elevated Elevated

Mortality 1-5% 10-20%

Class Activity
Case Study

Despite intense client teaching, R.H. presents to the

ED with hyperglycemic hyperosmolar syndrome.
• She has been ill with the flu and has not taken her metformin
as prescribed.
• R.H.’s admitting blood glucose level is 832 mg/dL.
• She is admitted to the ICU

8. What will be the priority nursing

assessments/interventions for R.H.?
Case Study
Several days after being admitted
for hyperglycemia,
• R.H.’s blood glucose level drops to 56
mg/dL.
• R.H. remains alert and oriented.

9. What are your priority nursing

interventions?
Heart: HTN & Atherosclerosis

Kidney: Renal Failure

Eye: Retinopathy leads to Blindness

Nerves : Neuropathy “loss sensation”

Diabetes Complications