NUR 342

ADULT HEALTH I
Unit I

Assessment and Management

of Patients With Diabetes
Mellitus
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Diabetes Mellitus
A group of diseases characterized by

hyperglycemia due to defects in insulin

secretion, insulin action, or both
Affects more than 23 million people in the U.S.
Almost 1/3 of cases are undiagnosed
Prevalence is increasing
Minority populations and the elderly are
disproportionately affected
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Functions of Insulin
Transports and metabolizes glucose for energy

Stimulates storage of glucose in the liver and muscle

as glycogen
Signals the liver to stop the release of glucose
Enhances the storage of dietary fat in adipose tissue
Accelerates transport of amino acids into cells
Inhibits the breakdown of stored glucose, protein,
and fat
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Classifications of Diabetes
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
Diabetes mellitus associated with other conditions or

syndromes

See Table 51-1, p. 1418

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Type 1 Diabetes
Insulin-producing beta cells in the pancreas are destroyed by an autoimmune

process: Antibodies against islet cells and endogenous insulin

Beta cell destruction decreased insulincontinued glucose production by

liver fasting hyperglycemia

If blood glucose > renal threshold for glucose (180-200mg/dl) glucose in

urine + excessive loss of fluid & electrolytes osmotic diuresis

Glycogenolysis and gluconeogenesis occur unrestrained r/t lack of insulin

hyperglycemia continues. Fat breakdown occursketone bodies

producedketoacidosis

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Type 1 Diabetes
Requires insulin, as little or
no insulin is produced
Onset is acute and usually
occurs before age 30
5% to 10% of persons with
diabetes
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Type 2 Diabetes
Decreased sensitivity to insulin (insulin resistance) and impaired
beta cell function results in decreased insulin production
90% to 95% of person with diabetes
More common in persons over age 30 and in the obese
Slow, progressive glucose intolerance
Treated initially with diet and exercise
Oral hypoglycemic agents and insulin may be used

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Pathogenesis of Type 2 Diabetes

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Complications of Diabetes
Complications of diabetes may develop in

anyone with type 1 or type 2 diabetes

Emphasize to the patient that even if not required

to take insulin, he or she does have diabetes and

must control the disease to prevent further health
problems and complications
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Risk Factors
Type 1: not inherited but a genetic predisposition

combined with immunologic and possibly

environmental (viral) factors
Type 2: family history of diabetes, obesity, race/
ethnicity, age greater than 45 years, previously
identified impaired fasting glucose or impaired
glucose tolerance, hypertension 140/90, HDL
35, and/or triglycerides 250, history of
gestational diabetes, and babies over 9 pounds
See Chart 51-1, p. 1417
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Clinical Manifestations
Three Ps
Polyuria
Polydipsia
Polyphagia
Fatigue, weakness, vision changes, tingling or

numbness in hands or feet, dry skin, skin lesions or

wounds that are slow to heal, and recurrent infections
Type 1 may have sudden weight loss, nausea, vomiting,
and abdominal pain if DKA has developed
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Diagnostic Findings
Fasting blood glucose of 126 mg/dL or more
Random glucose exceeding 200 mg/dL+ symptoms of DM
Gerontologic considerations; age-related elevation of blood

glucose

See Chart 51-2, p. 1420: Criteria for the Diagnosis of

Diabetes Mellitus

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Monitoring Glucose and Ketone Levels

Self-monitoring of blood glucose (SMBG)
Glycosylated hemoglobin

HgbA1C or A1C: test for average blood

glucose levels over 2-3 months
Normal values 4-6%
Urine testing: Limited use, not accurate reflection
Of blood sugar; renal threshold for blood sugar is
180-200 mg/dl, far above ideal blood sugar levels
Urine ketones tested when BS>240mg/dl for 2
Consecutive tests;illness, gestational DM
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Treatment Goal Is to Normalize

Blood Glucose Levels
Intensive control

dramatically
decreases vascular
and neuropathic
complications

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Dietary ManagementGoals
Provide optimal nutrition including all essential

food constituents

Meet energy needs

Achieve and maintain a reasonable weight
Prevent wide fluctuations of blood glucose levels
Decrease serum lipids, if elevated

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Role of the Nurse

Be knowledgeable about dietary management
Communicate important information to the dietician or other

management specialists

Reinforce patient understanding

Support dietary and lifestyle changes

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Meal Planning
Consider food preferences, lifestyle, usual eating times, and

cultural/ethnic background

Review diet history and need for weight loss, gain, or maintenanc

Consider caloric requirements and calorie distribution throughout

the day

Carbohydrates: 50% to 60% carbohydrates, emphasize whole

grains

Fat: 20% to 30%, with <10% from saturated fat and <300 mg

cholesterol

Fiber
Provide exchange lists: Sample menus, p. 1423

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Glycemic Index

Describes how much a food increases blood glucose

Combining starchy food with protein- and fat-containing

food slows absorption and glycemic response

Raw or whole foods tend to have lower response than
cooked, chopped, or pureed foods
Eating whole fruits rather than juices decreases the
glycemic response due to fiber-slowing absorption
Adding food with sugars may produce lower response if
eaten with foods that are more slowly absorbed

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Other Dietary Concerns

Alcohol
Nutritive and non-nutritive

sweeteners

Reading labels

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Exercise
Lowers blood sugar
Aids in weight loss
Lowers cardiovascular risk

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Exercise Precautions
Exercise when blood sugar levels are elevated (above 250

mg/dL) and ketones are present in urine should be avoided

Insulin (endogenous) normally decreases with exercise;

patients on exogenous insulin should eat a 15-g

carbohydrate snack before moderate exercise to prevent
hypoglycemia
If exercising to control or reduce weight, insulin must be

adjusted
Potential exists for postexercise hypoglycemia
Need to monitor blood glucose levels
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Exercise Recommendations
Encourage regular daily exercise
Gradual increase in exercise period is encouraged
Modify exercise regimen to patient needs and

presence of diabetic complications or potential

cardiovascular problems
Conduct exercise stress test for patients older than age
30 who have 2 or more risk factors (recommended)
Gerontologic considerations, p. 1441
Age-related changes that may affect diabetes and its
management.

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Monitoring Glucose and Ketone Levels:

Self-monitoring of blood glucose (SMBG)

Fasting: 70-110mg/dl, plasma; 60-110 finger stick capillary

blood (Kee, 2005); for diabetic 90-130mg/dl or as directed
by HCP (NMIE, J/A 2005)
Glycosylated hemoglobin

HgbA1C or A1C: test for average blood

glucose levels over 2-3 months
Normal values 4-6%; Diabetic goal <7%
Urine testing: Limited use, not accurate reflection

of blood sugar; renal threshold for blood sugar is

180-200 mg/dl, far above ideal blood sugar levels
Urine ketones tested when BS>240mg/dl for 2
consecutive tests, illness, gestational DM
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Insulin Therapy
Blood glucose monitoring
Categories of insulin: see Table 51-3,

1428.

Rapid-acting, Lispro (Humalog)

Short-acting, Regular (Humulin R)
Intermediate-acting: NPH (Humulin N)
Long Acting: Ultralente
Very long-acting: Glargine (Lantus)

Inhaled insulin: Exubera

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Insulin Therapy
Blood glucose monitoring
Categories of insulin: see Table 51-3,

1428

Rapid-acting, Lispro (Humalog)

Short-acting, Regular (Humulin R)
Intermediate-acting: NPH (Humulin N)
Long Acting: Ultralente
Very long-acting: Glargine (Lantus)

Inhaled insulin: Exubera

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Normal Pancreatic Insulin Release

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One Injection Per Day

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Two Injections Per Day

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Three or Four Injections Per Day

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Insulin Pump

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Teaching Patients Insulin

Self-Management
Use and action of insulin
Symptoms of hypoglycemia and hyperglycemia

Required actions
Blood glucose monitoring
Self-injection of insulin: see Charts 51-7, p. 1439 and 51-8, p.

1440 Outcome Criteria for Determining Effectiveness of Selfinjection of Insulin Education

Insulin pump use, p. 1432

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Suggested Sites
For Insulin
Injection

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Insulin Pump

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Insulin Pump with Syringe

and Connection to Needle Site

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What category of insulin is

rapid acting?
A. Humalog
B. Humalog R
C. Humulin N
D. Glargine (Lantus)

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ANSWER

Humalog is a rapid-acting
insulin. Humalog R is a shortacting insulin. Humulin N is an
intermediate-acting insulin.
Glargine (Lantus) is a very
long-acting insulin.

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Oral Antidiabetic Agents

Used for patients with type 2 diabetes who cannot be

treated with diet and exercise alone

Combinations of oral drugs may be used

Major side effects: hypoglycemia
Nursing interventions: monitor blood glucose and assess

for hypoglycemia and other potential side effects

Patient teaching
See Table 51-6, p. 1435

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Oral Antidiabetic Agents

Sulfonylureas: 1ST, 2ND generation:

Glyburide/Micronase
Biguainides: Metformin/Glucophage
Alpha Glucosidase Inhibitors: Acarbose
(Precose)
Thiazolidinediones: Rosiglitazone/Avandia
Meglitinides: Repaglinide/Prandin

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Oral Antidiabetic Agents

Sulfonylureas: 1ST, 2ND generation: Glyburide/Micron

Biguainides: Metformin/Glucophage
Alpha Glucosidase Inhibitors: Acarbose (Precose)
Thiazolidinediones: Rosiglitazone/Avandia
Meglitinides: Repaglinide/Prandin
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor:

Januvia

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Sites of Action of Oral Antidiabetic

Agents

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Acute Complications of Diabetes

Hypoglycemia
Diabetic ketoacidosis (DKA)
Hyperglycemic hyperosmolar nonketotic

syndrome (HHNS), or hyperosmolar

nonketotic coma, or hyperglycemia
hyperosmolar syndrome (HHS)
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Hypoglycemia
Abnormally low blood glucose level (below 50 to 60

mg/dL)

Causes include too much insulin or oral hypoglycemic

agents, too little food, and excessive physical activity

Manifestations
Adrenergic symptoms: sweating, tremors, tachycardia,
palpitations, nervousness, and hunger

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Hypoglycemia (cont.)
Manifestations (cont.)
Central nervous system symptoms: inability to
concentrate, headache, confusion, memory lapses,
slurred speech, numbness of lips and tongue,
irrational or combative behavior, double vision, and
drowsiness
Severe hypoglycemia may cause disorientation,
seizures, and loss of consciousness
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Assessment
Onset is abrupt and may be unexpected
Symptoms vary from person to person
Symptoms also vary related to the rapid

decrease in blood glucose and usual blood

glucose range
Decreased adrenergic response may affect
symptoms in persons who have had
diabetes for many years probably related
to autonomic neuropathy
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Management of Hypoglycemia
Treatment must be immediate
Give 15 g of fast-acting, concentrated carbohydrate
3 or 4 glucose tablets
4 to 6 ounces of juice or regular soda (not diet soda)
6 to 10 hard candies
2 to 3 teaspoons of honey

Retest blood glucose in 15 minutes, retreat if <70 mg/dL or if

symptoms persist more than 10 to 15 minutes and testing is not

possible

Provide a snack with protein and carbohydrate unless the patient

plans to eat a meal within 30 to 60 minutes

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Emergency Measures
If the patient cannot swallow or is

unconscious:
Subcutaneous or intramuscular glucagon 1 mg
25 to 50 mL 50% dextrose solution IV

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Diabetic Ketoacidosis (DKA)

Caused by an absence of or inadequate amount of insulin

resulting in abnormal metabolism of carbohydrate, protein,

and fat

Clinical features
Hyperglycemia
Dehydration
Acidosis

Manifestations include polyuria, polydipsia, blurred vision,

weakness, headache, anorexia, abdominal pain, nausea,

vomiting, acetone breath, hyperventilation with Kussmaul
respirations, and mental status changes

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Pathophysiology of DKA
See page 1443

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Assessment of DKA
Blood glucose levels vary between 300 to

800 mg/ dL
Severity of DKA is not related to blood
glucose level
Ketoacidosis is reflected in low serum
bicarbonate and low pH; low PCO2 reflects
respiratory compensation
Ketone bodies in blood and urine
Electrolytes vary according to water loss and
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Prevention
Sick day rules: see Chart 51-9, p. 1444
Assess for underlying causes
Diagnosis and proper management of diabetes

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Treatment of DKA

Rehydration with IV fluid

IV continuous infusion of regular insulin
Reverse acidosis and restoration of electrolyte balance
Note: rehydration leads to increased plasma volume
and decreased K+; insulin enhances the movement of
K+ from extracelluar fluid into the cells
Monitor
Blood glucose and renal function/UO
EKG and electrolyte levels: potassium
VS, lung assessments, signs of fluid overload

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Treatment of DKA

Rehydration with IV fluid

IV continuous infusion of regular insulin
Reverse acidosis and restoration of electrolyte balance
Note: rehydration leads to increased plasma volume
and decreased K+; insulin enhances the movement of
K+ from extracelluar fluid into the cells
Monitor
Blood glucose and renal function/UO
EKG and electrolyte levels: potassium
VS, lung assessments, signs of fluid overload

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Treatment of DKA

Rehydration with IV fluid

IV continuous infusion of regular insulin
Reverse acidosis and restoration of electrolyte balance
Note: rehydration leads to increased plasma volume
and decreased K+; insulin enhances the movement of
K+ from extracelluar fluid into the cells
Monitor
Blood glucose and renal function/UO
EKG and electrolyte levels: potassium
VS, lung assessments, signs of fluid overload

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Hyperglycemic Hyperosmolar
Nonketotic Syndrome
Hyperosmolality and hyperglycemia occur due to

lack of effective insulin; ketosis is minimal or

absent
Hyperglycemia causes osmotic diuresis with loss
of water and electrolytes; hypernatremia and
increased osmolality occur
Manifestations include hypotension, profound
dehydration, tachycardia, and variable neurologic
signs due to cerebral dehydration
High mortality
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Hyperglycemic Hyperosmolar
Nonketotic Syndrome
Hyperosmolality and hyperglycemia occur due to

lack of effective insulin; ketosis is minimal or

absent
Hyperglycemia causes osmotic diuresis with loss
of water and electrolytes; hypernatremia and
increased osmolality occur
Manifestations include hypotension, profound
dehydration, tachycardia, and variable neurologic
signs due to cerebral dehydration
High mortality
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Treatment of HHNS
Rehydration
Insulin administration
Monitor fluid volume and electrolyte status
Prevention
BGSM
Diagnosis and management of diabetes
Assess and promote self-care management skills

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Long-Term Complications of
Diabetes
Macrovascular complications
Accelerated atherosclerotic changes

Coronary artery disease, cerebrovascular disease, and periphe

vascular disease

Microvascular complications
Diabetic retinopathy and nephropathy

Neuropathic changes

Peripheral neuropathy, autonomic neuropathies, hypoglycem

unawareness, sudomotor neuropathy, & sexual dysfunction

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Widespread Complications of
Diabetes Mellitus

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Widespread Complications of
Diabetes Mellitus

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Diabetic Retinopathy

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Monofilament test used to assess

sensory threshold in patients with
diabetes mellitus

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Neuropathic Ulcers on Pressure Points

In Areas with Diminished Sensation

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Nursing ProcessAssessment
of the Patient With Diabetes
Assess the primary presenting problem
In addition, assess needs related to diabetes
Assess patient knowledge of diabetes and

diabetes care skills

Assess blood glucose levels
Assess skin
Explain preventive health measures
See Chart 51-3, p. 1421, Assessing the
patient with diabetes mellitus
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Nursing ProcessesDiagnosis
of the Patient With Diabetes
Imbalanced nutrition
Risk of impaired skin

integrity

Deficient knowledge

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Collaborative Problems/
Potential Complications
Inadequate control of blood glucose

levels
DKA
HHNS

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Nursing ProcessPlanning the

Care of the Patient With Diabetes
Major goals include improved nutritional

status, maintenance of skin integrity (ie, foot

care), ability to perform basic diabetes selfcare skills, as well as preventive care for the
avoidance of chronic complications of
diabetes, and absence of complications

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Improving Nutritional Status

Monitor nutritional intake, blood glucose,

urine ketones, and daily weight

Monitor for signs and symptoms of DKA or
HHNS
Plan food intake with the primary goal of
glucose control
Implement alternative strategies to ensure
adequate nutritional if alterations in diet are
indicated
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Maintaining Skin integrity

Assess skin daily
Provide diabetic foot care: see Chart 51-11, p.

1455

Position legs and feet, keeping heels off bed;

use a bed cradle

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Teaching Patients Self-Care

Assess knowledge and adherence to plan of care
Provide basic information about diabetes, its cause,

and symptoms, and acute and chronic complications

and their treatment
Teach self-care activities to prevent long-term
complications including foot care, eye care, and riskfactor management
Include family in plan of care
Provide information, encourage health promotion
activities, and recommend health screenings
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Special Issues in Diabetes Care

Patient undergoing surgery
Important: Approaches to managing insulin &
glucose on day of surgery
Hospitalized diabetic patient
Hyperglycemia
Hypoglycemia
Dietary alterations
Stress
Gerontologic considerations

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