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DIABETES MELLITUS
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Background …
• Normally, blood glucose levels are controlled by
insulin. When the blood glucose elevates (for
example, after eating food), insulin is released
from the pancreas to normalize the glucose level.
• In patients with diabetes, the absence or
insufficient production of insulin causes
hyperglycemia.
• Need insulin for glucose to cross cell membrane
• No insulin  no glucose in the cell and Glucose
stays in the blood.
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Epidemiology

• The prevalence DM is found to be 4.6% among

male and 2.7 among female where the total percent
is 3.6. Regarding, residence it is found that the
prevalence was higher in urban population i.e.,
6.5% and 2.9% among rural population(Aryal KK
et.al, 2015 ).
(The Burden and Determinants of Non Communicable Diseases
Risk Factors in Nepal)
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Definition
• Diabetes is a chronic medical condition, meaning
that although it can be controlled, it lasts a
lifetime.

• Diabetes mellitus is a group of metabolic diseases

characterized by high blood sugar (glucose) levels
that result from defects in insulin secretion, or its
action, or both.
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Definition
• A multisystem disease related to:
▫ Abnormal insulin production, or
▫ Impaired insulin utilization, or
▫ Both of the above

• It is described as a metabolic disorder of multiple

aetiology characterized by chronic hyperglycaemia
with disturbances of carbohydrate, fat and
protein metabolism resulting from defects in
insulin secretion, insulin action, or both.
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Classification
Type 1 Diabetes Mellitus

Type 2 Diabetes Mellitus

Gestational Diabetes

Others-Secondary Diabetes and prediabetes

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Type 1 DM
 Also called insulin-dependent diabetes mellitus
(IDDM) or juvenile-onset diabetes.
 Type 1 diabetes develops when the body’s immune
system destroys pancreatic beta cells
 This form of diabetes usually strikes children and
young adults, although disease onset can occur at any
age.
 Type 1 diabetes may account for 5% to 10% of all
diagnosed cases of diabetes.
 Patients with type 1 diabetes need to take insulin
injections for the rest of their life.
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Risk factors
• Risk factors for type 1 diabetes may include :
▫ Autoimmune
▫ Genetic factors and
▫ Environmental factors.
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Risk factors…
• In autoimmune diseases, such as type 1 diabetes,
the immune system mistakenly manufactures
antibodies and inflammatory cells that are directed
against and cause damage to patients' own body
tissues.
• In persons with type 1 diabetes, the beta cells of the
pancreas, which are responsible for insulin
production, are attacked by the misdirected immune
system.
• It is believed that the tendency to develop abnormal
antibodies in type 1 diabetes is, in part, genetically
inherited, though the details are not fully
understood.
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Risk factors…
• Exposure to certain viral infections (mumps
and Coxsackie viruses) or other environmental
toxins may serve to trigger abnormal antibody
responses that cause damage to the pancreas cells.

• Some of the antibodies seen in type 1 diabetes

include anti-islet cell antibodies, anti-insulin
antibodies and anti-glutamic decarboxylase
antibodies..
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Type 2 diabetes

 Was previously called non- insulin-dependent

diabetes (NIDDM) or adult-onset diabetes.
 Type 2 diabetes may account for about 90% to 95%
of all diagnosed cases of diabetes.
• It usually begins with insulin resistance
▫ Body tissues do not use insulin properly
 As the need for insulin rises, the pancreas
gradually loses its ability to produce insulin.
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Type 2 diabetes
Type 2 diabetes is typically
recognized in adulthood,
usually after age 45 years
Finally, the liver continues
to produce glucose through
a process called
gluconeogenesis despite
elevated glucose levels.
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RISK FACTORS…TYPE 2 DM
Type 2 diabetes is associated with:
 Older age
 Obesity
 Family history of diabetes
 History of gestational diabetes
 Impaired glucose metabolism
 Physical inactivity
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Gestational DM
 A form of glucose intolerance that is diagnosed in
some women during pregnancy.
 This occurs usually in the 2nd and 3rd trimester
 It is due hormones secreted by the placenta i.e.
Human placental lactogen, which inhibit the
action of insulin
 It is also more common among obese women and
women with a family history of diabetes.
 During pregnancy, gestational diabetes requires
treatment to normalize maternal blood glucose
levels to avoid complications in the infant.
 Gestational DM
• Associated with risk for cesarean delivery,
perinatal death, and neonatal complications.

• After pregnancy, 5% to 10% of women with

gestational diabetes are found to have type 2
diabetes.

• Women who have had gestational diabetes have a

20% to 50% chance of developing diabetes in the
next 5-10 years.
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Secondary diabetes..
• Secondary diabetes refers to elevated blood sugar
levels from another medical condition.
• Secondary diabetes may develop when the
pancreatic tissue responsible for the production of
insulin is destroyed by disease, such as chronic
pancreatitis , trauma, or surgical removal of the
pancreas.
• Diabetes can also result from other hormonal
disturbances, such as excessive growth hormone
production (acromegaly) and Cushing's syndrome.
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Secondary diabetes..
• In acromegaly, a pituitary gland tumor at the base
of the brain causes excessive production of growth
hormone, leading to hyperglycemia.
• In Cushing's syndrome, the adrenal glands produce
an excess of cortisol, which promotes blood sugar
elevation.
 Drug induced hyperglycemia:
◦ Beta-blockers - Inhibit insulin secretion.
◦ Calcium Channel Blockers - Inhibits secretion of
insulin
◦ Corticosteroids - Cause peripheral insulin resistance
and gluconeogensis
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Prediabetes
• Prediabetes is a term used to distinguish people
who are at increased risk of developing diabetes.
• People with prediabetes have impaired fasting
glucose (IFG) or impaired glucose tolerance
(IGT). Some may have both IFG and IGT.
• IFG - when fasting blood sugar level is elevated
(100-125mg/dl).
• IGT - when blood sugar level is elevated (140-
199mg/dl after a 2 hour oral glucose tolerance
test).
 Causes of DM…
▫ Pancreatic Disorders e.g. Inflammatory,
neoplastic.
▫ Defects in the formation of the insulin
(biologically less active insulin molecules)
▫ Destruction of Beta cells due to viral infection
(coxackie),
▫ Chemical agent(rodentcides)
▫ Decreased insulin sensitivity, due to decreased
number of insulin receptors.
▫ Genetic Defects
▫ Auto-immunity.
Risk factors
Type 2 is more common in people who:

 Are overweight/obesity.
 Are 45 or older.
 Are physically inactive.
 Have a parent or sibling
with type 2 diabetes.
Risk factors …
 Have abnormal cholesterol levels.
 Have had gestational diabetes.
 Have high blood pressure.
 Dietary habit
 Environmental triggers stimulate an autoimmune
response
▫ Viral infections (mumps, rubella, )
▫ Chemical toxins
Obesity
-Obesity is often diagnosed by using a body mass
index (BMI).
-Healthy weight as BMI between 19 – 25.
-Obesity defined as BMI > 30.
-Waist circumference :
-Increased risk:
male > or equal to 94cm
female > or equal to 80cm
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Pathophysiology of type 1 DM …
Genetic
Immunologic
Environmental factors such as viral, toxin

Destruction of beta cells

Decreased insulin production

Uncontrolled glucose production by liver

Fasting hyperglycemia
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Pathophysiology of type 1 DM …

Glucose from meal remains in blood (due to

decreased insulin)

PP hyperglycemia
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Pathophysiology of type 1 DM …

Fasting hyperglycemia PP hyperglycemia

Re-absorption of glucose is limited in kidney

Glucose in urine

Osmotic diuresis- loss of fluid and electrolyte

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Pathophysiology of type 1 DM …

Fat metabolism

Ketone body formation

DKA
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Pathophysiology of type 2 DM …
• Two main problems
 Insulin resistance
 Impaired insulin secretion
• Exact mechanism leading to insulin resistance
unknown, although genetic factors may play a
role

To overcome the resistance and to maintain

blood glucose level, increased production of
insulin is required
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Pathophysiology of type 2 DM …
But beta cells cannot keep up with this increased
demand

Increased glucose level

Type 2 diabetes
PATHOPHYSIOLOGY

•
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Main symptoms of DM
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Main symptoms of DM..

• High amounts of glucose in the urine can cause
increased urine output and lead to dehydration.
• Dehydration causes increased thirst and water
consumption.
• Insulin is an anabolic hormone, that is, one that
encourages storage of fat and protein
• A relative or absolute insulin deficiency eventually
leads to weight loss despite an increase in appetite.
• Some untreated diabetes patients also complain of
fatigue, nausea and vomiting.
• Patients with diabetes are prone to developing
infections of the bladder, skin, and vaginal areas.
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Diagnosis
• According to clinical feature
• According to blood sugar test
▫ Fasting plasma glucose (FPG) ≥ 126 mg/dl (7.0
mmol/l) OR
Symptoms ,such as polyuria, polydipsia, unexplained
weight loss
▫ A random plasma glucose ≥ 200 mg/dl (11.1 mmol/l)
OR
Plasma glucose ≥ 200 mg/dl ( 11.1 mmol/l) 2 hours
after a 75g glucose load OR
Hb1C ≥ 6.5%.
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Treatment and Management

• The goal of diabetes treatment is to normalize
insulin activity & blood glucose levels to reduce
the development of vascular & neuropathic
complications.
• Diabetes management has 5 components:
- Nutritional therapy
- Exercise
- Monitoring
- Pharmacologic therapy
- Education
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Nutritional management
• Nutrition, diet & weight control are the
foundation of diabetes management.

• Control of total caloric intake to attain or

maintain a reasonable body weight & control of
blood sugar.
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Dietary guidelines
• Consider the patient’s food preferences, lifestyle,
usual eating times, and ethnic and cultural
background.
• Caloric requirements: Calorie controlled diet are
planned by first calculating a person’s energy needs
and caloric requirements based on age, gender,
height and weight.
• According to American Dietetic Association
recommend that for all level of calorie intake 50%
to 60% of calories should be derived from
carbohydrates, 20 to 30% from fat and 10 to 20%
from protein.
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Dietary guidelines
• Provide 20-30% of total intake of calories but
saturated fat intake should not exceed 10% of total
energy.
• Cholesterol consumption should be restricted and
limited to 300 mg or less daily.
• Protein should be derived from both animal and
vegetable sources.
• Excessive salt intake is to be avoided. It should be
particularly restricted in people with hypertension
and those with nephropathy.
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Dietary guidelines..
• Protein intake can range between 10-15% total energy
(0.8-1 g/kg of desirable body weight). Requirements
increase for children and during pregnancy.
Carbohydrates provide 50-60% of total caloric content of
the diet. Carbohydrates should be complex and high in
fibre.
Food guide pyramid: commonly used by type 2 DM
patients. It consist of 6 food groups:
i. bread, rice, cereal & pasta.
ii. Fruits
iii. Vegetables group
iv. Meat, poultry, dry beans, eggs & nuts
v. Milk, yogurt & cheese
vi. Fats, oils & sweets.
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Exercise
• Patient who have blood glucose levels exceeding 250 mg/dl
and who have ketones in their urine should not begin
exercising until the urine test results are negative for
ketones and the blood glucose level is close to normal.
• Physical activity promotes weight reduction and improves
insulin sensitivity, thus lowering blood glucose levels.
• physical activity or exercise for at least 30 min/day is
recommended.
• Patients who requires insulin should be taught to eat a 15
gm carbohydrates snack with a protein before engaging in
moderate exercise to prevent unexpected hypoglycemia.
• Patients with type 2 diabetes who are not taking insulin or
an oral agent may not need extra food before exercise.
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Monitoring
• Self monitoring of blood glucose who were receiving
insulin should monitor blood glucose level 2-4 times
daily (usually before meals and at bed time).
- Those not receiving insulin- 2-3 times/week
including 2 hour postprandial test.
- Asked to keep a record or logbook of blood glucose
levels so that they can detect patterns.
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Oral hypoglycemic agent

• It may be effective for patient who have type 2
diabetes that cannot be treated with diet and
exercises.
• It may be discontinued temporarily when insulin
is needed if the patient develop hyperglycemia due
to infection , trauma or surgery.
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Oral Hypoglycaemic Medications

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Insulin Therapy
• In type 1 diabetes exogenous insulin must be
administered for life long.
• In type 2 diabetes insulin may be necessary on a long
term basis to control glucose level if diet and oral
agent fail.
• Insulin dose require for the individual patient is
defined by the level of blood glucose.
• There are two main groups of insulins used : human
insulins and analog insulin, made by recombinant
DNA technology.
• The concentration of insulin available in 100 and 40
units per milliliter.
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Types of Insulin
1. Rapid-acting (analogs) (10-15 min, 2-4 hrs).
2. Short-acting (Regular)(1/2-1 hr, 4-6 hrs).
3. Intermediate-acting (NPH) (2-4 hrs, 16-24 hrs).
4. Premixed(70/30)
5. Long-acting (Lantus) (1 hr, 24 hrs).
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Education
• Diabetes is a chronic illness requiring a life time
special self management behavior. Because diet ,
physical exercise, stress affect diabetic control
• They must learn daily self care skill to prevent acute
fluctuations in blood glucose
• Diabetic patient must have knowledge about
nutrition , side effect of medications , exercise ,
blood glucose monitoring technique , meal planning.
• Those patient who need insulin therapy must have
skill on self administration insulin including
maintaining sterile technique during self
administration
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Complications
• Acute Complication:
▫ Diabetic ketoacidosis
▫ Hyperglycemia hyperosmolar state
▫ Hypoglycemia
▫ Diabetic coma
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Diabetic ketoacidosis

• Diabetic ketoacidosis (DKA) is an acute and

dangerous complication that is always a medical
emergency.

• Low insulin levels in tissue cause the liver to turn

fatty acid to ketone for fuel (ketosis). Elevated
levels of ketone bodies in the blood decrease the
blood's pH, leading to DKA.
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Sign and symptoms of DKA

• Tachycardia
• Dehydration / hypotension
• Tachypnea / respiratory distress
• Abdominal tenderness (may resemble acute
pancreatitis or surgical abdomen)
• Lethargy / cerebral edema / possibly coma
• Other signs:
▫ Kussmaul breathing (deep, labored breaths)
▫ Fruity odor to breath (due to acetone)
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Hyperglycemia hyperosmolar state

• A person with very high (usually considered to be
above 300 mg/dl (16 mmol/L)) blood glucose
levels, water is osmotically drawn out of cells into
the blood and the kidneys eventually begin to
dump glucose into the urine.

• This results in loss of water and an increase in

blood osmolality.
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Hypoglycemia
• Hypoglycemia is an acute complication of diabetes
treatments.
• The patient may become agitated, sweaty, weak etc..
• Consciousness can be altered or even lost in extreme
cases, leading to coma, seizures, or even brain
damage and death.
• In patients with diabetes, this may be caused by
several factors, such as too much or incorrectly timed
insulin, too much or incorrectly timed exercise, not
enough food
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Diabetic coma

• It is a medical emergency in which a person with

diabetes mellitus is in comatose .It is due to:

▫ Severe diabetic hypoglycemia

▫ Diabetic ketoacidosis
▫ Hyperosmolar nonketotic coma
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Chronic complications:
Micro vascular complications:
▫ Diabetes nephropathy
▫ Diabetes retinopathy
▫ Diabetes neuropathy
▫ Diabetic foot
Macro vascular complication :
▫ Coronary artery disease
▫ Cerebrovascular disease
▫ Peripheral vascular disease.
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NURSING MANAGEMENT

• ASSESSMENT
▫ Focus on sign and symptoms of hyperglycemia
▫ Assess the sign of DKA including ketonuria
orthostatic hypotension, kussmaul respirations and
lethargy
▫ Monitor the laboratory signs for metabolic acidosis
and electrolyte imbalances
▫ Assess the emotional status of the patient
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NURSING MANAGEMENT…
• Nursing diagnoses
▫ Risk for fluid volume deficit related polyuria and
dehydration
▫ Imbalance nutrition related to imbalance of
insulin or food
▫ Deficit knowledge about diabetes self care skills
▫ Anxiety related to misinformation and fear of
complications
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NURSING MANAGEMENT…
• Goals
▫ Maintain fluid and electrolyte balance
▫ Maintain diet and control of blood sugar level
▫ Increase self care skills and avoid misconception
▫ Decreased anxiety
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NURSING MANAGEMENT…
• Nursing interventions
▫ Maintaining fluid and electrolyte balance
 Measure intake and output
 Administer intravenous fluids and electrolytes as
ordered
 Measure electrolytes and monitor closely
 Monitor vitals signs to detect dehydration:
 Tachycardia
 Orthostatic hypotension
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NURSING MANAGEMENT…
• Improving nutritional intake
▫ Plan diet with glucose control
▫ Encourage to eat full meal and snacks with
diabetic diet
▫ Make arrangement for extra snacks before
increased physical activity
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NURSING MANAGEMENT…
• Increasing knowledge about self care
▫ Teach preventive behaviors for long term diabetic
complications
▫ Cover simple treatment modalities, recognition
and prevention of acute complications
▫ Instruct the family so that they may assist in
diabetes management
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Nursing management…
• Reducing anxiety
▫ Provide emotional support
▫ Clear misconceptions about diabetes
▫ Encourage patient to perform the skill feared
most: self injection
▫ Glucose monitoring through glucometer
▫ Give positive reinforcement for self care behaviors
attempted
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Nursing Management…
• Health education
▫ diet
▫ Exercise
▫ Medication
▫ Glucose monitoring
▫ complications
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Self-Care

 Patients should be educated to practice self-care. This allows

the patient to assume responsibility and control of his / her
own diabetes management. Self-care should include:

◦ Blood glucose monitoring

◦ Body weight monitoring
◦ Foot-care
◦ Personal hygiene
◦ Healthy lifestyle/diet or physical activity
◦ Identify targets for control
◦ Stopping smoking