Assessment

Increased frequency of urination (polyuria)

Increased thirst or fluid intake (polydipsia)
Weight loss despite hunger
Increased food intake (polyphagia)
Family history
Weakness and fatigue, dizziness
Recurrent blurred vision
Pruritis,skin infections,vaginitis
Type 1 Diabetes Mellitus
Ketonuria
Type 2 Diabetes Mellitus
Obese
Nursing Intervention
Plan a Physical Activity Program
Help the client to choose an exercise regimen and to set resonable goals, because any increase in activity is beneficial.
Instruct client to start at a well tolerated intensity level and duration, with gradual increase in intensity and duration until present
exercise goals are reached.
Prevent Complications from Physical Activity
Instruct to be adequately hydrated before starting exercise.
Instruct to avoid alcohol and beta-blockers because they may increase the risk of hypoglycemia and hyperglycemia.
Provide Instructions on Blood Glucose Monitoring
Discuss the normal blood glucose range, goals for good control (individualized for each client), when to test, how to record test
results, amd what to do when abnormal results are obtained.
Normal blood glucose level: 70-100 mg/dL
Instruct to obtain glucose monitoring 30 mins-1 hour before meal.
Provide Instruction on Insulin Administration
Insulin syringes- capacities of 0.25, 0.30, 0.50 and 1 mL. Instruct that short syringe are not recommended for obese cients because
variability of insulin absorption when injected into adipose tissue.
Insulin Pens- can hold 150-300 "U" of insulin.
Needle-Free Technology- Jet injectors, which are pen-like devices, can be used in place of insulin syringes for deivery of insulin.
The problem of safe disposal of needles is avoided.
Insulin Storage- avoid temperature extremes of less than 36 degrees F or greater than 86 degrees F. Vials in use can be kept at
room temperatures for about 1 month. Mark the date on the vial when it was initially opened. Do not use any insulin beyond its
expiration date.
Site Selection and Rotation- Instruct the client to give injections in one area, about an inch apart, until the whole area has been
used, before changing to another site. Tell the client to avoid sites above muscles that will be exercised heavily that day, because
exercise increases the rate of absorption. Emphasize the importance of adhering to definite injection plan for avoiding tissue
damage. Rotate injection sites in one area to decrease the variability of absorption.
Surigical Client
Monitor for rejection, adverse effects of immunosuppressive agents, infection, and occlusion of vessels.
Careful monitoring for changes in vital signs, laboratory values, fluid and electrolyte status, and physical manifestations is
important to determine the onset of complications: thrombosis, infection, and rejection.
Screening and Diagnosis Guidelines for Diabetes Mellitus
GUIDELINES FOR TESTING FOR DM
Testing for DM should be considered in all adults at age 45.
If results are normal, testing should be repeated at 3-year intervals.

Testing should be considered at a younger age or performed more often for clients with the following risk factors:
Obesity (>120% of desirable body weight or a BMI above 25kg/m2)
Habitual physical inactivity
Polycystic ovary syndrome
DM in a first-degree relative
Racial predisposition (as in African-American, Hispanic, Native American populations)
In woman who have given birth to a bay weighing more than 9 pounds or who have a history of gestational DM.
Hypertension (BP >130/80mmHg)
A high density lipoprotein level <35mg/dl or triglyceride level >250 mg/dl
On previous testing, impaired glucose tolerance or impaired fasting glucose levels.

GUIDELINES FOR DIAGNOSIS OF DM

Fasting plasma glucose level above 126mg/dl (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
Manifestations of DM plus casual plasma glucose concentration above 200mg/dl (11.1mmol/L). Casual is defined as any tie
 of day without regard to time since last meal. Classic manifestations include polyuria, polydipsia, and unexplained weight
loss.
A 2-hour postload glucose level above 200mg/dl during an oral glucose tolerance test. This test should be performed using a
glucose load containing the equivalent of 75g of anhydrous glucose dissolved in water.
PLASMA GLUCOSE VALUES
Fasting plasma glucose
<110 mg/dl Normal fasting glucose
110-125mg/dl Impaired fasting glucose
>126 mg/dl Diagnosis of DM
Oral glucose tolerance test, 2 hours after eating
<140 mg/dl Normal glucose tolerance
140-199mg/dl Impaired glucose tolerance
>200 mg/dl Diagnosis of DM
FASTING BLOOD GLUCOSE LEVEL
Provides the best indication of overall glucose homeostasis and is preferred method of diagnosing DM
Normal: 70-110 mg/dL
Sample is drawn when the client has not ingested any nutrients other than water for al least 8 hours
The blood sample generally reflects glucose level from hepatic production
<126mg/dL indicates Diabetes mellitus
Values between 110-125 mg/dL indicates IFG
CASUAL BLOOD GLUCOSE LEVEL
Clients may also diagnosed with DM based on clinical manifestation and a casual (random) blood glucose level is
greater than 200 mg/dL
Sample can be drawn anytime of daw without regard to fasting
Elevated blood glucose level may:
occur after meals
After stressful events
In sample drawn from an IV site
Or in cases of DM
POSTLOAD BLOOD GLUCOSE LEVEL
Postload or postprandial (after a meal) glucose level can also be drawn and used to diagnosed DM.
Postload glucose samples are drawn 2 hours after a standard meal and reflects the effeciency of insulin-mediated
glucose uptake by peripheral tissues
Normally, blood glucose level should return to fasting levels within 2 hours. A 2-hour postload glucsoe level greater
than 200 mg/dL during an oral glucose tolerance test (OGTT) is confirmation for a diagnosis of diabetes mellitus
In older adults, postload levels are higher typically increasing by 5-10 mg/dL per decade after 50 years because of the
normal decline in glucose tolerance associated with aging
Smoking and drinking coffee can lead to falsely elevated values at 2 hours
Whereas, strenuous exercise can lead to falsely decreased values
MANAGEMENT OF COMPLICATIONS
Major interventions particularly in the early phases, include achievement of euglycemia and normalization of blood pressure.
When retinopathy threatens vision, outpatient laser therapy (photocoagulation) is usually recommended.
Although extensive photocoagulation usually diminishes peripheral vision and may decrease night vision, its success in
preserving good visual acuity makes worthwhile despite side effects.
If the extent or location of the damage makes photocoagulation ineffective, or if the vitreous is too scarred or clouded with
blood, vitrectomy is performed.
Vitrectomy- surgical procedure that removes the vitreous and replace it with saline solution.
Nephropathy
Single most common cause of stage 5 CKD.
35% - 45% of clients with type 1 DM are found to have nephropathy 15 20 years after diagnosis.
20 % of clients with type 2 DM are found to have nephropathy 5 to 10 years after diagnosis.
Consequence of nephropathy includes damage and eventual obliteration of the capillaries that supply the kidney. This damage
leads in turn to a complex of pathologic changes and manifestations :
Intercapillary glomerulosclerosis
Nephrosis
Gross albumin Uria
Hypertension

Risk Factors:
 Poor glycemic control,
Duration of disease and
Hypertension

Clients with nephropathy monitor their blood glucose levels and blood pressure at home.
Tought to eat low-protien diet and avoid nephrotoxic drugs ( e.g. Gentamicin)
ACE inhibitors to decrease microalbuminuria.
If contrast dye is required for radiographic study, mannitol may be ordered but the client must drink fluids after the test to
clear the dye from the kidneys.
Serum creatinine levels should be assessed before the administration of the contrast dye or other nephrotoxic agents.
Unsuccesful treatment of nephropathy progress to stage 5 kidney disease (ESRD)
Treatment:
Hemodialysis
Peritoneal dialysis
Kidney transplantation

Neuropathy
Most common chronic complication of DM.
Because nerve fibers do not have their own blood supply, they depend on diffusion of nutrients and oxygen across the
membrane. When axon and dendrites are not nourished, their transmission of impulses slows.
Both temporary and permanent neurologic problems may develop in clients with DM.
May be mild or so severe that the quality of life is affected.
Identified causes of diabetic nephropathy:
Vascular insufficiency
Chronic elevations in blood glucose level
Hypertension
Cigarette smoking
Clients with mononeuropathy or polyneuropathy and may have sensory or motor impairment.
Client with high blood glucose level often experiences nerve pain ; numbness, stabbing, tingling, or burning sensation referred
as Diabetic Peripheral Neuropathy (DPN).
Pregabalin(Lyrica)- first medication approved by the FDA to treat pain that occurs with DPN and postherpetic neuralgia (phn).
Lyrica also approved as an adjunctive treatment for partial onset of seizures in adults.
Side effects: dizziness, sleepiness, dry mouth, swelling of hands and feet, blurred vision.
Mononeuropathy
Or focal neuropathy involves a single nerve or group of nerves.
Produced sharp, stabbing pains usually caused by an infarction of the blood supply.
Treatment may include surgical decompression for compression lesions.
Polyneuropathy
Or diffuse neuropathy involves the sensory and autonomic nerves.
Sensory neuropathy is the most common type.
Commonly assessed by bilateral, symmetrical and affecting the lower extremities.
The client describes tingling, numbness, burning and mild to total sensory loss.
Treatment includes: foot care education to prevent trauma and ulcers.
Painful neuropathy may be treated with tricyclic antidepressant, phenytoin, or carbamazepine.
Autonomic Neuropathy
Manifest itself in its effect on pupillary, cardiovascular, gastrointestinal, and genitourinary functions.
Pupillary - interferes with the pupils ability to adapt to the dark. Pupil dilation is inadequate. Clients are at risk for accidents
when driving at night. The environment should be well lighted at night.
Cardiovascular evidenced by an abnormal response to exercise. A fixed heart rate may be noted. Orthostatic hypotension
may occur. Resting tachycardia is another possible effect.
Gastrointestinal commonly affects gastrointestinal tract.
Client may have dysphagia. Abdominal pain, nausea, vomiting, malabsorption, postprandial hypoglycemia, diarrhea,
constipation or fecal incontinence.
Gastroparesis may give feeling of stomach fullness.
May be alleviated with Metoclopramide (Reglan)
Genitourinary
Bladder hypotonicity or neurogenic bladder is a common manifestation.
Manifestation includes :
Straining with urination
Infrequent urge to urinate with long periods of time between voiding
Decreased urine stream
 In male client, autonomic neuropathy can contribute to erectile dysfunction and retrograde ejaculation.
Penile injections, implantable devices, or Sildenafil (Viagra) may improve functions.
Women with autonomic neuropathy may experience painful intercourse, which estrogen-containing lubricants can resolve.

MEDICAL MANAGEMENT

DIET
Dietary control with caloric restriction of CHO and saturated fats to maintain ideal body weight.
Weight reduction
EXERCISE
Regularly scheduled, moderate exercise performed at least 3o minutes most days of the week promotes:
Utilization of CHO
Assists weight control
Enhances the action of insulin
Improves cardiovascular fitness
MEDICATION
Oral antidiabetic agents for patients for patients with Type 2 DM who do not achieve glucose control with diet and exercise.
Mechanism:
Stimulation of insulin secretion from functioning beta cells
Reduction of hepatic glucose production
Enhancement of peripheral sensitivity to insulin
Reduced absorption of CHO in the intestines
Oral Anti-diabetic Agents
SULFONYLUREAS
Chlorpropamide
Tolbutamide
Glimepiride
Glizide
BIGUANIDES
Metformin
Glucophage
MEDICATIONS
Insulin therapy for patients with Type 1 DM who require replacement.
Hypoglycemia may result as well as rebound hyperglycemia (Somogyi effect)
Commonly results in increased appetite and weight gain
GENERAL HEALTH
The American Diabetes Association (2003) recommends the following goals of treatment:
Glycemic control
HbA1c <7%
Preprandial glucose 90-130 mg/dl
Peak Postprandial glucose <180 mg/dl
GENERAL HEALTH
b. BP < 130/80 mmhg
c. Lipid control
 LDL <100 mg/dl
HDL >40 mg/dl
Triglycerides <150 mg/dl
d. Microalbumin (spot urine) <30 mcg/mg creatinine