REPORTERS

(E5)
Barcenilla, Deborah
Celeste, Rose Paulette
Deala, Kathleen Faye
Fernandez, Lynch Heldegard
Jimenez, Laurene Duls
Lay, Felicidade
Oliverio, Arnel Jon
Rubino, April Glenn
Sabellina, Madilou Dimple
Sagnoy, Eunice
Sumagang, Ernest
DIABETES MELLITUS
 WHAT
IS
DIABETES
MELLITUS ? ? ?
Diabetes mellitus is a chronic
systemic disease characterized by
either a deficiency of insulin or a
decreased ability of the body to use
insulin.
 CLASSIFICATIONS OF
DIABETES MELLITUS

◘ TYPE I (INSULIN DEPENDENT)

◘ TYPEII (NON-INSULIN DEPENDENT)

 Comparison of Type I and Type II Diabetes Mellitus

FEATURE TYPE I TYPE II

►Age at onset Usually occurs before age 30, but may Usually occurs after age 30 but can
occur at any age occur at children
►Incidence ~10% ~90%
►Type of onset Usually abrupt, w/ rapid onset of Insidious, may be asymptomatic;
hyperglycemia body adapts to slow onset of hyper
gylcemia
►Endogenous Little or none Below normal, normal, or above
Insulin normal
Production
►Body weight Ideal body weight or thin 85% are obese: may be of ideal
at onset body weight
►Ketosis prone to ketosis Resistant to ketosis
►Manifestations Polyuria, polydipsia, polyphagia, Often none,may be mild symptoms
fatigue of hyperglycemia
►Oral hypogly Not effective Effective
cemic agents
►Exogenous Dependent on insulin for survival 20-30% of clients require insulin
insulin adminis
tration
 Pathogenesis of Type I Diabetes Mellitus
Genetic Predisposition (susceptibility)
Chromosome 6: HDL-DR3 and –DR4 increased, HDL-DR2 decreased

Environmental Insult Autoimmunity

-Viral Infection - Lymphocyte infiltration
- Toxic chemical agents -Insulitis

Immunologic response
- Islet cell antibodies
- Cell-mediated immunity

ß cell destruction

Lack of insulin release

Insulin-dependent Diabetes Mellitus

 Pathogenesis of Type II Diabetes Mellitus
Hereditary Factors Obesity

Delayed or insufficient Insulin resistance

Insulin secretion (receptor defect
or other events)

Increased insulin demand

ß Cell exhaustion and dysfunction

Hyperglycemia

Non-insulin dependent diabetes (NIDDM)

 HISTORY
- Symptoms r/t the diagnosis of diabetes:
Symptoms of hyperglycemia
Symptoms of hypoglycemia
Frequency, timing, severity, and resolution
-Results of blood glucose monitoring
-Status, symptoms, & management of chronic
complications of diabetes
Eye, kidney,nerve, genitourinary & sexual,
bladder, & gastrointestinal
Cardiac, peripheral vascular, foot complications
associated w/ diabetes
-Adherence to/ability to follow prescribed dietary
management plan
-Adherence to prescribed exercise regimen
-Adherence to/ability to follow prescribed
pharmacologic treatment
-Use of tobacco, alcohol & prescribed & over-the-
counter drugs
-Lifestyle, cultural, psychosocial, & economic factors
that may affect treatment
-Effects of diabetes or its complications on functional
status
 PHYSICAL EXAMINATION
► Blood pressure (sitting & standing to
detect orthostatic changes)
►Body mass index ( height & weight)
► Fundoscopic examination
►Foot examination ( lesions, signs of infection,
pulses}
► Skin examinations ( lesions & injection sites)
►Neurologic examination
Vibratory & sensory examination using
monofilament
Deep tendon reflexes
►Oral examination
 CLINICAL
MANIFESTATIONS
Elimination:
Polyuria, nocturia, diarrhea or constipation
Food and fluid:
Hunger, thirst, nausea, weight loss or obesity
Neurosensory :
Decreased sensation to pain and temperature in
the feet, blurred vision, headaches, cataracts, halos
around lights
Mobility:
Muscle weakness, tiredness, wrist-drop, ankle-
drop
Skin:
Infection( frequent boils and ulcerations,)
Sexuality:
impotence, vaginal discharge, increased
susceptibility to vaginal infection
Circulation:
Cold extremeties, loss of hair in toes; thin, shiny
skin, painful calves when walking, numbness and
tingling of lower extremeties
Psychosocial:
verbalizations of inability to cope and change in
lifestlye, negative feeling about the body
MANAGEMENT
 MAIN GOAL:

To normalize insulin activity and blood

glucose levels to reduce the development
of vascular and neuropathic conditions
FIVE COMPONENTS OF DIABETES
MANAGEMENT

►Nutritional Therapy
►Exercise

►Monitoring

►Pharmacologic Therapy

►Education
 NUTRITION THERAPY

CALORIC REQUIREMENTS
-Calorie-controlled diets are planned by first calculating a
person’s energy needs and caloric requirements based on age,
gender, height, and weight.
CARBOHYDRATES
-It should be eaten in moderation to avoid high postprandial
blood glucose levels
FATS
-Include both reducing the total percentage of calories from fat
sources to less than 30% of total calories and limiting the
amount of saturated fats to 10% of total calories
FIBER
-Increased fiber in the diet may also improve blood glucose levels
and decrease the need for exogenous insulin.
 SAMPLE MENU

EXCHANGES SAMPLE SAMPLE SAMPLE

LUNCH # 1 LUNCH # 2 LUNCH # 3

2 starch 2 slices of bread Hamburger bun 1 cup cooked pasta

3 meat 2 oz sliced turkey & 1 oz 3 oz lean beef patty 3 oz boiled shrimp
low fat cheese
1 vegetable lettuce, tomato, onion green salad ½ cup plum tomatoes
1 fat 1 tsp mayonnaise 1 tbsp salad dressing 1 tsp olive oil
1 fruit 1 medium apple 1 ¼ cup watermelon 1 ¼ cup fresh
strawberries
“free items” unsweetened iced tea, diet soda, 1 tbsp catsup Ice water w/ lemon,
(optional) mustard, pickle pickle, onions garlic, basil
 EXERCISE
-Exercise is extremely important in diabetes management because
of its effect on lowering blood glucose and reducing cardiovascular
risk factors. It lowers blood glucose levels 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.
-Exercise also alters blood lipid concentrations, increasing levels of
high-density lipoproteins and decreasing total cholesterol and
triglyceride levels.
 GENERAL PRECAUTIONS FOR
EXERCISE

-Use proper footwear and, if appropriate,

other protective equipment
- Avoid exercise in extreme heat or cold
- Inspect feet daily after exercise
- Avoid exercise during periods of poor
metabolic control
 MONITORING GLUCoSE LEVELS AND KETONES

SELF MONITORING OF BLOOD GLUCOSE (SMBG)

This allows for detection and prevention of
hypoglycemia and hyperglycemia and plays a crucial role
in normalizing blood glucose levels, which in turn may
reduce the risk of long-term diabetic complications
Recommended for patients with:
-unstable diabetes (severe swings from very high to very
low blood glucose levels w/in a 24-hour day)
-a tendency to develop severe ketosis or hypoglycemia
-hypoglycemia without warning symptoms
FREQUENCY:
SMBG is recommended 2-4 times daily (usually
before meals and at bedtime). For patients who take
insulin before each meal, SMBG is required at least 3
times daily before meals to determine each dose.
Patients not receiving insulin may be instructed to
assess their blood glucose levels at least 2-3 times per
week .
 CONTINUOUS GLUCOSE MONITORING
SYSTEM

A sensor attached to an infusion set, which is similar

to an insulin pump infusion set, is inserted
subcutaneously in the abdomen and connected to the
device worn on a belt. After 72 hours, the data from the
device are downloaded and blood glucose readings are
analyzed.
 GLYCATED HEMOGLOBIN

is a blood test that reflects average blood glucose

levels over a period of approximately 2-3 months.
When blood glucose levels are elevated, glucose
molecules attach to hemoglobin in red blood cells. The
longer the amount of glucose in the blood remains
above normal, the more glucose binds to hemoglobin
and the higher the glycated hemoglobin level becomes.
 URINE GLUCOSE TESTING

Monitor diabetes on a daily basis

TESTING FOR KETONES

Ketones are byproducts of fat breakdown, and they

accumulate in the blood and urine. Ketones in the urine
signal that control of type I diabetes is deteriorating,
and the risk of DKA is high.
 PHARMACOLOGIC THERAPY
INSULIN THERAPY
In type I diabetes, exogenous insulin must be
administered for life because the body loses the
ability to produce insulin.
In type II diabetes, insulin may be necessary on a
long-term basis to control glucose levels if meal
planning and oral agents are ineffective.
 CATEGORIES OF INSULIN

TIME COURSE AGENT ONSET PEAK DURATION INDICATIONS

Rapid acting Lispro 10-15min 1 hr 2-4hr Used for rapid reduction of

Aspart 5-15min 40-50 2-4 hr glucose level, to treat post-

min prandial hyperglycemia &/

or to prevent noturnal hypo
glycemia
Short-acting regular(huma ½-1 hr 2-3h 4-6h usually administered 20-30
log R) min before a meal ;may be
taken alone or in combina
tion w/ longer-acting insulin
Intermediate- NPH(neutral 2-4 hr 4-12h 16-20h usually taken after food
Acting protamine Ha
gedorn)
Long-acting ultralente (“UL”) 6-8hr 12-16h 20-30h Used primarily to control
fasting glucose level
Very long- Glargine(lantus) 1h conti 20-30 h used for basal dose
Acting nuous
(no peak
ALTERNATIVE METHODS OF INSULIN DELIVERY

-INSULIN PENS
-JET INJECTORS
-INSULIN PUMPS
-IMPLANTABLE AND INHALANT INSULIN
DELIVERY
NURSING IMPLICATIONS FOR PHARMACOLOGY:INSULIN
NURSING RESPONSIBILITIES

-Discard vials of insulin that have been open for several weeks or whose
expiration date has passed.
-Refrigerate extra insulin vials not currently in use, but do not freeze them.
-Store insulin in a cool place, and avoid exposure to temperature extremes or
sunlight.
-Store compatible mixtures of insulin for no longer than 1 month at room temp.
Or three mo. at 36-46 F
-Discard any vial w/ discoloration, clumping, granules or solid deposits on the
sides
-Monitor and maintain a record of blood glucose readings 30 min before each
meal and bedtime
-If breakfast is delayed, also delay the administration of rapid-acting insulin
-monitor food intake, and notify the physician if food is not being consumed
-monitor electrolytes, BUN levels and creatinine
Observe injection sites for manifestations of hypersensitivity
lipodystrophy, and lipoatrophy
-If symptoms of hypoglycaemia occur, confirm by testing blood
glucose level,
and administer an oral source of a fast-acting CHO, such as
juice, milk or crackers
-If symptoms of hyperglycemia occur, confirm by testing blood
glucose level, and notify the physician

CLIENT AND FAMILY TEACHING

- The manifestations of DM to patient

-Self administration of insulin w/ a return demonstration:
a. Wash hands carefully
b. Have a vial of insulin, the insulin syringe w/ needle, and alcohol
pads ready to use.
c. Remove the cover from the needle
d. Fill the syringe w/ an amount of air equal to the # of units
of insulin, and insert the needle into the vial
e. Push air into the vial, invert the vial, and withdraw the
prescribed
units of insulin
f. Replace the cover over the needle
g. Wipe the selected site w/ alcohol
h. pinch up a fold of skin, and insert the needle into the tissue at
the recommended angle
i. Insert the insulin
j. Withdraw the needle; if desired, apply firm pressure to the site
for a few seconds
k. Recap the needle and dispose
-Follow instructions for mixing insulins
-Always keep an extra vial of insulin available
-Be aware of the signs of hypersensitivity responses,
hypoglycaemia and hyperglycemia
-Keep candy or a sugar source available at all times to
treat
hypooglycemia, if it occurs
-Vision may be blurred during the first 6-8 weeks of insulin
-therapy because of fluid changes in the eye
-Avoid alcoholic beverages w/c may cause hypoglycaemia
-Follow guidelines for sick days:

a. Never omit insulin

b. Always monitor blood glucose and/or urine ketones at least
every 2-4 hours
c. Always drink plenty of fluids
d. Get as much rest as possible
e. Contact the physician if there is persistent fever, vomiting,
SOB, severe pain in the abdomen, DHN, loss of vision, chest pain,
[persistent diarrhea, blood glucose levels above 250 or ketones in
the urine.

-Establish a plan for rotating injection sites, and observe closely

for
changes in tissues
CONCENTRATIONS OF INSULIN:

Insulin is dispense in 3 concentrations: 40 U/mL, 100 U/mL, and

500 U/mL. Each of the basic types of insulin is available in both
U-40 and U-100 concentrations. Only regular insulin is also
dispensed in U-500 concentrations

TYPES OF INSULIN:

1. Regular insulin
-unmodified crystalline insulin, clear in appearance and is the
only
type that can be given by IV route, used to treat DKA
2. NPH and protamine Zinc insulin suspension
-preparations in w/c the insulin has been conjugated w/
protamine, a large protein.
-these preparations appear cloudy when properly mixed prior to
injection
3. SEMILENTE, LENTE, and ULTRALENTE INSULINS

-have altered solubility as a result of a modification of the insulin

itself; no foreign proteins are added

ROUTES OF ADMINISTRATION

All insulins are given parenterally. Only regular insulin is given by

both subcutaneous and IV routes;
all others are given only subcutaneously.
If the IV route is not available, regular insulin may also be
administered intramuscularly in an emergency
situation.
SYRINGE AND NEEDLE SELECTION:

Insulin is administered in sterile, single-use, disposable insulin

syringes, calibrated in U/ml.
Syringes for administering U-100 insulin can be purchased in
either 0.3 ml (30 U), 0.5 ml(50 U)
or 1.0 ml (100 U ) size. Most insulin syringes are manufactured w/
a needle permanently
attached in a 25-36 gauge, 0.5 inch size. If these type of syringe
is not available, an insulin
syringe and a 25 gauge, 0.5 inch or 0.75 inch needle should be
used.
SITES OF INJECTION:

-Abdomen- site that allows the most rapid absorption

-Deltoid muscle
-thigh
-hip
MIXING INSULINS:

When a person w/ diabetes requires more than 1 type of insulin

, mixing is required
to avoid administering 2 injections/dose. 2 different
concentrations are administered
because a single dose of intermediate-acting or long-acting
insulin rarely provides
adequate control of blood glucose levels.
GENERAL GUIDELINES:

-Commercially mixed insulins are recommended if the insulin

ratio is appropriate
for the requirements of the client.
-Only insulins of like concentrations should be mixed.
-Regular insulin maybe mixed w/ all other types of insulin; It may
be injected immediately
after mixing or stored for future use.
-NPH insulin and PZI insulin maybe mixed only w/ regular insulin.
-Lente insulin preparations maybe mixed with each other, mixing
w/ regular insulin or w/ PZI and NPH insulin is not recommended.
-Do not mix human and animal insulins.
-Always withdraw regular insulin first to avoid contaminating the
regular insulin
w/ intermediate-acting insulin.
MIXING INSULINS: 10 Units of regular and 20 units of NPH

1. Wash hands.
2. Inspect regular insulin for clarity.
3. Gently rotate NPH insulin to mix well.
4. Wipe off the top of both vials with an alcohol pad.
5. Draw 20 U of air into the syringe and inject air into the NPH vial.
Withdraw needle.
6. Draw 10 U of air into the syringe and inject air into the regular
vial.
7. Invert the vial and withdraw 10 U of regular insulin.
8. Insert the needle into the NPH vial, and carefully withdraw 20 U
of NPH insulin.
9. Administer the insulin.
10. Wash hands and properly dispose of the syringe.
HYPERSENSITIVITY RESPONSES

Manifestations of local reactions are a hardening and

reddening of the area that
develops over several hours. Local reactions result from a
contaminant in the insulin
and are more likely to occur when less purified insulin products
are used.
-Systemic reactions occur rapidly and are characterized by
widespread red, intensely
pruritic welts. Systemic responses are due to an allergy to the
insulin itself and are
most common with beef insulin. The client can be desensitized
by administering small
doses of purified pork or human insulin, followed by
progressively larger doses.
OTHER DIETARY CONSIDERATIONS:
SODIUM
The recommended daily intake is 1000mg of sodium per 1000kcal,
not to exceed 3000mg.
Table salt and processed foods high in sodium must be avoided in
the diabetes meal plan.
SWEETENERS
Commercially produced non-nutritive sweeteners are approved
for use by the Food and Drug Administration.
Sweeteners include saccharine, aspartame, and acesulfame
potassium. The non-nutritive sweeteners
have neglidient amounts of kcal or no kcal and produced very
little or no changes in blood glucose levels.
Nutritive sweeteners are also used by diabetics. This includes
fructose, sorbitol, and xylitol.
The kcal content of these substances is similar to that of table
sugar but they cause less elevation in
blood glucose.
ALCOHOL
-Alcohol consumption may potentiate the hypoglycemic effects of
insulin and oral agents.
The American Diabetes Association recommends that men w/
diabetes consume no more than
2 drinks and women w/ diabetes no more than 1 drink per day.

NEEDS OF THE CLIENT WITH TYPE 2 DM

There are no specific guidelines for the type 2 diet, but in addition
to decreasing kcal,
it is recommended that the client consume 3 meals of equal size,
evenly spaced
approximately 4-5 hrs apart, w/ 1 or 2 snacks. The person with
type 2 DM should also decrease.
It should also decrease fat intake. If the exchange list is difficult to
use, calorie counting or
designing the diet by grams of fat maybe more useful.
NEEDS OF A CLIENT WITH TYPE 1 DM:

-Diet and insulin prescription must be integrated for optimal energy

metabolism and the prevention of hyperglycemia or hypoglycaemia
STRATEGIES IN MEETING GOALS:
-Glucose regulation requires correlating eating patterns with insulin
Onset and peak of actions.
-meals, snacks, and insulin regimens should be based on a
person’s lifestyle.
-meal planning depends on the specific insulin regimen prescribed
-Snacks are an important consideration in relation to the amount
and timing of exercise
-The diet plan must consider the availability of foods based on
occupational,
financial, religious, and ethnic constraints.
-Self-monitoring of blood glucose levels helps the client make
adjustments
for planned and unplanned changes in routines.
SICK DAY MANAGEMENT:

-Monitor blood glucose at least four times a day throughout an

illness
-Testing urine for ketones if blood glucose is greater than 240
mg/dl
-continue to take the usual insulin dose or oral hypoglycaemic
agent
-Sipping 8-12 oz of fluid each hour
-Substitute easily digested liquids or soft foods if solid foods are
not tolerated
-call the physician if client is unable to eat for more than 24 hours
or if vomiting and
diarrhea last for more than 6 hours
GENERAL GUIDELINES FOR TYPE 1 DM EXERCISE PROGRAMS:
-People who have frequent hyper or hypoglycaemia should avoid
prolonged exercise
until glucose control improves
-The risk of exercise induced hypoglycaemia is lowest before
breakfast, when free-insulin
levels tend to be lower, than they are before meals later in the day
or At bedtime
-Low-impact aerobic exercises are encourage
-Exercise should be, moderate and regular; brief, intense exercise
causes mild hyperglycemia,and prolonged exercise causes
hypoglycaemia
-Exercising at a peak insulin action time may lead to hypoglycaemi
-Self-monitoring of blood glucose levels is essential both before
and after an exercise
-Food intake may need to be increased to compensate for the
activity
-Fluid intake, especially water is essential
FOR TYPE 2:

-before the client begins the program, carefully assessed for

previously undiagnosed hypertension, neuropathy, retinopathy,
nephropathy, and cardiac ischemia
-Begin the [program w/ mild exercises, and gradually increase
intensity and duration
-Self monitoring of blood glucose levels before and after exercise
is essential
-Exercise at least 3 times a week or every other day, for at least
20-30 minutes
-Include muscle strengthening and low impact aerobic exercises
in the program
Long Term Complications of Diabetes:

a. Macrovascular complications
b. Microvascular complications
Diabetic retinopathy
Diabetic nephropathy
c. Neuropathy
 a. Macrovascular complications

- result from changes in the medium to

large blood vessels. Blood vessel walls
thicken, sclerose, and become occluded
by plaque that adheres to the vessel walls.
- blood flow is blocked.
 b. Microvascular complications
( microangiopathy)
- characterized by capillary basement membrane
thickening.

• Diabetic retinopathy
- caused by changes in the small
blood vessels in the retina, the area of
the eye that receives images and sends
information anout the images to the
brain.
- major cause of blindness among
clients with diabetes
• nephropathy
- renal disease secondary
to diabetic icrovascular
changes in kidney.
- damage to or and
eventual obliteration of the
capillaries that supply the
glomeruli of the kidney.

- common complication in
diabetes.
c. Diabetic neuropathies

-refers to a group of diseases that affect

all types of nerves, including peripheral
(sensorimotor), autonomic, and spinal
nerves.
 DIABETIC
KETOACIDOSIS
 Diabetic ketoacidosis is caused by an
absence or markedly inadequate amount
of insulin. This deficit in available insulin
results in disorders in the metabolism of
carbohydrates, protein, and fat.
 THREE MAIN FEATURES OF
DKA

►Hyperglycemia
►Dehydration and electrolyte loss
►Acidosis
PATHOPHYSIOLOGY
 Lack of insulin
-Decreased utilization of Increased
glucose by muscle, fat and liver breakdown of fat
-Increased production of
glucose by liver
Increased
fatty acids
Hyperglycemia
-Acetone breath
Blurred vision Polyuria -Poor appetite Increased
-Nausea ketone bodies

-Weakness Dehydration
-Headache -Nausea Acidosis
-Vomiting
Increased thirst -Abdominal pain
(polydipsia)
Increasingly rapid
respiration
 ASSESSMENT AND DIAGNOSTIC FINDINGS

-Blood glucose level may vary from 300 and 800 mg/dl
-Low serum bicarbonate: 0 to 15 mEq/L
-Low ph values: 6.8 to 7.3
-Low partial pressure of CO2 (PCO2 10 to 30 mmHg)
-Accumulation of ketone bodies
-Na+ and K+ concentration may be low, normal or high
-Increased levels of creatinine, BUN, and hematocrit seen
with dehydration
PREVENTION
 GUIDELINES TO FOLLOW DURING PERIODS OF ILLNESS
(SICK DAY RULES)
-Take insulin or oral antidiabetic agents as usual
-Test blood glucose and test urine ketones every 3 to 4
hours
-Report elevated glucose levels ( > 300 mg/dL or others
as specified) or urine ketones to your health care
provider
-If you take insulin, you may need supplemental
doses of regular insulin every 3 to 4 hours
-if you cannot follow your usual meal plan, substitute
soft foods ( e.q. 1/3 cup regular gelatin, 1 cup cream
soup, ½ cup custard, 3 squares graham crackers) six
to eight times per day
-If vomiting, diarrhea, or fever persists, take liquids
(e.q. ½ cup regular cola or orange juice, ½ cup broth,
1 cup gatorade) every ½ to 1 hour to prevent
dehydration and to provide calories
-Report nausea and vomiting and diarrhea to your
health care provider, extreme fluid loss may be
dangerous
-If you’re unable to retain oral fluids, you may require
hospitalization to avoid diabetic ketoacidosis and
possibly coma.
 NURSING
MANAGEMENT
-Monitoring fluid, electrolyte and hydration status,
glucose level
-Administering fluids, insulin, and other medication
-Monitor I and O to ensure adequate renal function
before administering potassium to prevent
hyperkalemia
-Monitor ECG for dysrhythmias
-Monitor vital signs ( especially BP and pulse),
arterial blood gases, breath sounds and mental
status