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1. INTRODUCTION:
Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop
responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells
of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment
includes changes in diet, oral medications, and in some cases, daily injections of insulin.
The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes,
and this form of diabetes occurs most often in people who are overweight and who do not exercise.
Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the
course of several years) and because it usually can be controlled with diet and oral medication. The
consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those
for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading.
Many people with Type II diabetes can control the condition with diet and oral medications, however,
insulin injections are sometimes necessary if treatment with diet and oral medication is not working.
The causes of diabetes mellitus are unclear, however, there seem to be both hereditary (genetic factors
passed on in families) and environmental factors involved. Research has shown that some people who
develop diabetes have common genetic markers. In Type I diabetes, the immune system, the body’s
defense system against infection, is believed to be triggered by a virus or another microorganism that
destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of
diabetes play a role.
In Type II diabetes, the pancreas may produce enough insulin, however, cells have become resistant to
the insulin produced and it may not work as effectively. Symptoms of Type II diabetes can begin so
gradually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and
frequent urination. Other symptoms may include sudden weight loss, slow wound healing, urinary tract
infections, gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while a
patient is seeing a doctor about another health concern that is actually being caused by the yet
undiagnosed diabetes.

2. Individuals who are at high risk of developing Type II diabetes mellitus include people who:
are obese (more than 20% above their ideal body weight)
have a relative with diabetes mellitus
belong to a high-risk ethnic population (African-American, Native American, Hispanic, or Native
Hawaiian)
have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg)
have high blood pressure (140/90 mmHg or above)
have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a triglyceride
level greater than or equal to 250 mg/dL
have had impaired glucose tolerance or impaired fasting glucose on previous testing
Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle changes. It is
best managed with a team approach to empower the client to successfully manage the disease. As part
of the team the, the nurse plans, organizes, and coordinates care among the various health disciplines
involved; provides care and education and promotes the client’s health and well being. Diabetes is a
major public health worldwide. Its complications cause many devastating health problems.
ANATOMY AND PHYSIOLOGY:
Every cell in the human body needs energy in order to function. The body’s primary energy source is
glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and
starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells
that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind
the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway
into the cell through which glucose can enter. Some of the glucose can be converted to concentrated
energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin
produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather
entering the cells.

3. PATHOPHYSIOLOGY:

4. DIAGNOSTIC TEST:
Several blood tests are used to measure blood glucose levels, the primary test for diagnosing diabetes.
Additional tests can determine the type of diabetes and its severity.
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 (see “Symptoms” above)
suggests a diagnosis of diabetes.

5. 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. A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is
done by taking a small sample of blood from a vein or fingertip. It must be repeated on another day to
confirm that it remains abnormally high (see “Criteria for diagnosis” below).
Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose level during the
past two to three months. It is used to monitor blood glucose control in people with known diabetes,
but is not normally used to diagnose diabetes. Normal values for A1C are 4 to 6 percent (show figure 3).
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.
The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram liquid
glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two hours later, a
second blood glucose level is measured.
Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen for
gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose level drawn
one hour later. For women who have an abnormally elevated blood glucose level, a second OGTT is
performed on another day after drinking a 100 gram glucose solution. The blood glucose level is
measured before, and at one, two, and three hours after drinking the solution.
MEDICATIONS:
When diet, exercise and maintaining a healthy weight aren’t enough, you may need the help of
medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes and some
people with type 2 diabetes must take insulin every day to replace what their pancreas is unable to
produce. Unfortunately, insulin can’t be taken in pill form because enzymes in your stomach break it
down so that it becomes ineffective. For that reason, many people inject themselves with insulin using a
syringe or an insulin pen injector,a device that looks like a pen, except the cartridge is filled with insulin.
Others may use an insulin pump, which provides a continuous supply of insulin, eliminating the need for
daily shots.

6. The most widely used form of insulin is synthetic human insulin, which is chemically identical to human
insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isn’t perfect. One of its
chief failings is that it doesn’t mimic the way natural insulin is secreted. But newer types of insulin,
known as insulin analogs, more closely resemble the way natural insulin acts in your body. Among these
are lispro (Humalog), insulin aspart (NovoLog) and glargine (Lantus).
A number of drug options exist for treating type 2 diabetes, including:
· Sulfonylurea drugs. These medications stimulate your pancreas to produce and release more insulin.
For them to be effective, your pancreas must produce some insulin on its own. Second-generation
sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase)
and glimepiride (Amaryl) are prescribed most often. The most common side effect of sulfonylureas is
low blood sugar, especially during the first four months of therapy. You’re at much greater risk of low
blood sugar if you have impaired liver or kidney function.
· Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to sulfonylureas,
but you’re not as likely to develop low blood sugar. Meglitinides work quickly, and the results fade
rapidly.
· Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class available in the
United States. It works by inhibiting the production and release of glucose from your liver, which means
you need less insulin to transport blood sugar into your cells. One advantage of metformin is that is
tends to cause less weight gain than do other diabetes medications. Possible side effects include a
metallic taste in your mouth, loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and
diarrhea. These effects usually decrease over time and are less likely to occur if you take the medication
with food. A rare but serious side effect is lactic acidosis, which results when lactic acid builds up in your
body. Symptoms include tiredness, weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is
especially likely to occur if you mix this medication with alcohol or have impaired kidney function.
· Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive tract that break
down carbohydrates. That means sugar is absorbed into your bloodstream more slowly, which helps
prevent the rapid rise in blood sugar that usually occurs right after a meal. Drugs in this class include
acarbose (Precose) and miglitol (Glyset). Although safe and effective, alpha-glucosidase inhibitors can
cause abdominal bloating, gas and diarrhea. If taken in high doses, they may also cause reversible liver
damage.

7. · Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and keep your liver
from overproducing glucose. Side effects of thiazolidinediones, such as rosiglitazone (Avandia) and
pioglitazone hydrochloride (Actos), include swelling, weight gain and fatigue. A far more serious
potential side effect is liver damage. The thiazolidinedione troglitzeone (Rezulin) was taken off the
market in March 2000 because it caused liver failure. If your doctor prescribes these drugs, it’s
important to have your liver checked every two months during the first year of therapy. Contact your
doctor immediately if you experience any of the signs and symptoms of liver damage, such as nausea
and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your skin and the whites of
your eyes (jaundice). These may not always be related to diabetes medications, but your doctor will
need to investigate all possible causes.
· Drug combinations. By combining drugs from different classes, you may be able to control your blood
sugar in several different ways. Each class of oral medication can be combined with drugs from any
other class. Most doctors prescribe two drugs in combination, although sometimes three drugs may be
prescribed. Newer medications, such as Glucovance, which contains both glyburide and metformin,
combine different oral drugs in a single tablet.
NURSING INTERVENTIONS:
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.
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.

8. 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.