diabetes mellitus , types and management including nursing management

2. Diabetes is a chronic disease, which occurs when the
pancreas does not produce enough insulin, or when the
body cannot effectively use the insulin it produces. This
leads to an increased concentration of glucose in the blood
(hyperglycaemia).
Diabetes mellitus is a group of metabolic diseases
characterized by increased levels of glucose in the blood
(hyperglycemia) resulting from defects in insulin secretion,
insulin action, or both
(American Diabetes Association [ADA], 2004).

3. Family history of diabetes (ie, parents or siblings with diabetes)
Obesity (ie, ≥20% over desired body weight or BMI ≥27 kg/m2)
Race/ethnicity (eg, African Americans, Hispanic Americans,
Native Americans, Asian Americans, Pacific Islanders)
Age ≥45 y
Previously identified impaired fasting glucose or impaired
glucose tolerance
Hypertension (≥140/90 mm Hg)
HDL cholesterol level ≤35 mg/dL (0.90 mmol/L)
History of gestational diabetes or delivery of babies over 9 lb

4. The cause of diabetes depends on the type.

5. classification Descriptions
Type 1 (Juvenile diabetes
Juvenile-onset diabetes, Insulin-dependent
diabetes mellitus (IDDM)
It is characterized by a lack of insulin production. Onset any
age, but usually young (<30 y) Usually thin at diagnosis;
recent weight loss
Type 2 (Adult-onset diabetes
Non–insulin-dependent diabetes (NIDDM)
It is caused by the body’s ineffective use of insulin. Onset
any age, usually over 30 yrs,Usually obese at diagnosis
Gestational diabetes Onset during pregnancy, usually in the second or third
trimester. Due to hormones secreted by the placenta, which
inhibit the action of insulin
Secondary diabetes (Diabetes mellitus
associated with other conditions or
syndromes
Accompanied by conditions known or suspected to cause the
disease: pancreatic diseases, hormonal abnormalities,
medications such as corticosteroids
Prediabetes Current normal glucose metabolism
Previous history of hyperglycemia (eg, during pregnancy or
illness)

6. Type 1 diabetes
Is partly inherited, and then triggered by certain infections,
with some evidence pointing at Coxsackie B4 virus. A genetic
element in individual susceptibility to some of these triggers
has been traced to particular HLA genotypes (i.e., the genetic
“self” identifiers relied upon by the immune system). The
onset of type 1 diabetes is unrelated to lifestyle.

8. The two main problems related to insulin in type 2 diabetes
are insulin resistance and impaired insulin secretion. In
type 2 diabetes, intracellular reactions are diminished,
making insulin less effective at stimulating glucose uptake
by the tissues.

11.  Nervousness
 Irritability
 Diaphoresis (heavy sweating)
 Hunger
 Weakness
 Tachycardia
 Fatigue
 Hypotension
 Palpitations
 Tachypnea
 Tremors or shaking Pallor
 Blurred or double vision
 Incoherent speech
 Headache Numbness of tongue and lips
 Confusion Coma
 Seizures

12.  History collection
 Physical examination
 Random blood glucose test — for a random blood glucose test, blood
can be drawn at any time throughout the day, regardless of when the
person last ate. A random blood glucose level of 200 mg/dL (11.1
mmol/L) or higher in persons who have symptoms of high blood
glucose suggests a diagnosis of diabetes.
 Fasting blood glucose test — fasting blood glucose testing involves
measuring blood glucose after not eating or drinking for 8 to 12 hours
(usually overnight). A normal fasting blood glucose level is less than
100 mg/dL.

13.  Hemoglobin A1C test (A1C) — The A1C blood test
measures the average blood glucose level during the past two to
three months. Normal values for A1C are 4 to 6 percent . The test
is done by taking a small sample of blood from a vein or fingertip.
 Oral glucose tolerance test — Oral glucose tolerance testing
(OGTT) is the most sensitive test for diagnosing diabetes and pre-
diabetes. However, the OGTT is not routinely recommended
because it is inconvenient compared to a fasting blood glucose
test.

14. 5 components of DM management
Nutritional therapy
Exercise
Monitoring
Pharmacologic therapy
Education

15. Providing all the essential food constituents (eg,
vitamins, minerals) necessary for optimal nutrition
Meeting energy needs
Achieving and maintaining a reasonable weight
Eating whole fruit instead of drinking juice decreases
the glycemic response, because fiber in the fruit slows
absorption.
Low sugar and fat diet

16. Exercise is extremely important in diabetes management
because of its effects on lowering blood glucose and
reducing cardiovascular risk factors. Exercise lowers blood
glucose levels by increasing the uptake of glucose by body
muscles and by improving insulin utilization.

17. Blood glucose monitoring is a cornerstone of diabetes
management
A continuous glucose monitoring system (CGMS) that can
continuously monitor blood glucose is now available. 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.
Glucometer tests
Urine glucose testing

18.  Sulfonylurea drugs. These medications stimulate pancreas to produce and
release more insulin. such as glipizide and glimepiride are prescribed most
often.
 Meglitinides. work quickly, and the results fade rapidly.
 Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this
class available One advantage of metformin is that is tends to cause less weight
gain than do other diabetes medications.
 Alpha-glucosidase inhibitors. These drugs block the action of
enzymes in digestive tract that break down carbohydrates. That
means sugar is absorbed into bloodstream more slowly
 Thiazolidinediones. These drugs make body tissues more sensitive to
insulin and keep liver from overproducing glucose.
 Drug combinations. By combining drugs from different classes, may
be able to control your blood sugar in several different ways

19.  In type 1 diabetes, exogenous insulin must be administered for
life because the body loses the ability to produce insulin.
 In type 2 diabetes ,insulin may be necessary on a long-term basis
to control glucose levels if meal planning and oral agents are
ineffective.
There are 5 categories of insulin
 Rapid-acting insulin Lispro (Humalog)Aspart (Novolog)
 Short-acting Regular (Humalog R, Novolin R, Iletin II
Regular)
 Intermediate-acting NPH (neutral protamine Hagedorn)
Humulin N, Iletin II Lente, Iletin II NPH, Novolin L [Lente],
Novolin N [NPH])
 Long-acting Ultralente (“UL”)
 Very long-acting Glargine (Lantus)

20.  Patients must become knowledgeable about nutrition,
medication effects and side effects, exercise, disease
progression, prevention strategies, blood glucose monitoring
techniques, and medication adjustment.
 One approach is to organize education using the seven tips for
managing diabetes are,
 Healthy eating
 Being active
 Monitoring
 Taking medicines
 Problem solving
 Reducing risks
 Healthy coping

21.  Advice patient about the importance of an individualized meal
plan in meeting weekly weight loss goals and assist with
compliance.
 Assess patients for cognitive or sensory impairments, which may
interfere with the ability to accurately administer insulin.
 Demonstrate and explain thoroughly the procedure for insulin
self-injection. Help patient to achieve mastery of technique by
taking step by step approach.
 Review dosage and time of injections in relation to meals,
activity, and bedtime based on patients individualized insulin
regimen.
 Instruct patient in the importance of accuracy of insulin
preparation and meal timing to avoid hypoglycemia.

22.  Explain the importance of exercise in maintaining or
reducing weight.
 Advise patient to assess blood glucose level before
strenuous activity and to eat carbohydrate snack before
exercising to avoid hypoglycemia.
 Assess feet and legs for skin temperature, sensation, soft
tissues injuries, corns, calluses, dryness, hair
distribution, pulses and deep tendon reflexes.
 Maintain skin integrity by protecting feet from
breakdown.
 Advice patient who smokes to stop smoking or reduce if
possible, to reduce vasoconstriction and enhance
peripheral flow.