Chapter 53

Diabetes

KEY POINTS

DIABETES MELLITUS

Etiology and Pathophysiology

• Diabetes mellitus (more commonly referred to as diabetes) is a chronic multisystem disorder of

glucose metabolism related to absent or insufficient insulin, impaired use of insulin, or both.

• Current theories link the causes of diabetes to genetic, autoimmune, and environmental factors.

Type 1 Diabetes

• Type 1 diabetes generally affects people under 40 years of age, although it can occur at any

age.

• Type 1 diabetes is the result of a long-standing autoimmune process in which the body’s own T

cells attack and destroy pancreatic β -cells, which are the source of the body’s insulin.

• Because the initial manifestation of type 1 diabetes is often rapid, the symptoms are usually

acute.

• The classic symptoms, polyuria, polydipsia, and polyphagia, are caused by hyperglycemia.

• The person with type 1 diabetes requires insulin therapy to sustain life. Without insulin, the

patient will develop diabetes-related ketoacidosis (DKA), a life-threatening condition resulting

in metabolic acidosis.

Type 2 Diabetes

• Type 2 diabetes accounts for around 90% of people with diabetes.

• In type 2 diabetes, the pancreas usually continues to make some insulin. However, the insulin

that is made is either insufficient for the needs of the body and/or is poorly used by the tissues.

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 There are many factors and several genes involved in the development of type 2 diabetes.

• One of the most important risk factors for developing type 2 diabetes is obesity.

• The manifestations of type 2 diabetes are more nonspecific and include fatigue, recurrent

infections, recurrent vaginal yeast infections, prolonged wound healing, and visual changes.

Prediabetes

• Prediabetes is a condition in which blood glucose levels are higher than normal but not high

enough for a diagnosis of diabetes.

• Long-term damage to the body, especially the heart and blood vessels, may already be

occurring in people with prediabetes.

• Teach people with prediabetes to take action to prevent or delay the development of type 2

diabetes. Encourage them to have their blood glucose and A1C checked regularly

Gestational Diabetes

• Gestational diabetes develops during pregnancy and is usually screened for and detected at 24

to 28 weeks of gestation by an oral glucose tolerance test.

• Although most women with gestational diabetes will have normal glucose levels within 6

weeks postpartum, their risk for developing type 2 diabetes is 63% within 16 years.

Other Specific Types of Diabetes

• Other types of diabetes can occur because of another medical condition or treatment that causes

abnormal blood glucose levels. These conditions result from injury to, interference with, or

destruction of the β-cell function of the pancreas.

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• Conditions include Cushing syndrome, hyperthyroidism, recurrent pancreatitis, cystic fibrosis,

hemochromatosis, parenteral nutrition, or use of certain drugs, including corticosteroids or

certain antipsychotics.

Diagnostic Studies

• A diagnosis of diabetes is based on 1 of 4 methods: fasting plasma glucose, random plasma

glucose measurement with symptoms, 2-hour oral glucose tolerance test, and/or an A1C test.

Interprofessional Care

• The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute

complications of hyperglycemia and hypoglycemia, and prevent or delay the onset and

progression of long-term complications. These goals are most likely to be met when the patient

maintains blood glucose levels as near to normal as possible.

Drug Therapy: Insulin

• Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet specific

metabolic needs.

• Insulin is divided into 2 main categories: short-acting (bolus) and long-acting (basal) insulin.

• Bolus insulin is used at mealtimes to prevent postprandial hyperglycemia and/or to bring down
an elevated glucose level.

• Basal insulin provides a background level of insulin throughout the day.

• A variety of insulin plans are recommended for patients depending on his or her needs and

preferences.

• Insulin is most often given by subcutaneous injection. IV administration of regular insulin can

be given when immediate onset of action is desired.

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• The speed with which peak serum concentrations are reached varies with the anatomic site for

injection. The fastest subcutaneous absorption is from the abdomen.

• An insulin pump can be used to give continuous short-acting insulin. It is programmed to

deliver a continuous infusion 24 hours a day with boluses at mealtime and to bring down

elevated blood glucose levels.

Hypoglycemia, allergic reactions, lipodystrophy, hypertrophy, and the Somogyi effect are

problems associated with insulin therapy.

• Lipodystrophy may occur if the same injection sites are used frequently. The incidence has

decreased with the use of human insulin.

Hypertrophy is a thickening of the subcutaneous tissue. Injecting into a hypertrophied site

may result in erratic insulin absorption.

• Elevated morning glucose levels may be due to the Somogyi effect. This is a rebound caused by

hypoglycemia during the night that stimulates a counterregulatory response.

• The dawn phenomenon is characterized by hyperglycemia that is present on awakening in the

morning, resulting from the increased release of counterregulatory hormones in the predawn

hours.

Drug Therapy: Oral and Noninsulin Injectable Agents

• These agents primarily work on the 3 main defects of type 2 diabetes: (1) insulin resistance, (2)

decreased insulin production, and (3) increased hepatic glucose production. These drugs may

be used in combination with agents from other classes or with insulin to achieve blood glucose

goals.

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Oral Agents

• Metformin (Glucophage) is a biguanide glucose-lowering agent. The primary action of

metformin is to reduce glucose production by the liver. The ADA algorithm for the management

of type 2 diabetes recommends the use of metformin combined with lifestyle interventions as the

first-line therapy. Metformin is available in many combination drugs as well.

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 Sulfonylureas increase insulin production from the pancreas. Since they can cause

hypoglycemia, it is important to teach patients how to recognize and manage low blood glucose.

Sulfonylureas are sometimes added if metformin and lifestyle interventions are not effective.

• Meglitinides increase insulin production from the pancreas. Because they are rapidly

absorbed and eliminated, they have a lower risk of hypoglycemia than with the sulfonylureas.

They are taken before meals, usually resulting in dosing 3 times a day.

• α-Glucosidase inhibitors, also known as “starch blockers,” work by slowing down

carbohydrate absorption in the small intestine.

• Thiazolidinediones are most effective for people who have insulin resistance. Due to their

severe adverse effects, the 2 drugs in this class are rarely used.

Noninsulin Injectable Agents

• Glucagon-like peptide (GLP)-1 receptor agonists target the incretin hormones. They

stabilize blood glucose levels, slow gastric emptying, increase satiety, and have the additional

effect of reducing body weight.

• Sodium-glucose co-transporter 2 (SGLT2) inhibitors decrease renal glucose reabsorption

and increase urinary glucose excretion.

• Dipeptidyl peptidase IV (DPP-4) inhibitors slow the degradation of the incretin hormone

GLP1. This results in inhibited secretion of glucagon, increased insulin secretion, slowed gastric

emptying, and decreased appetite.

• Pramlintide (Symlin) is a synthetic analog of human amylin, a hormone secreted by the β

cells of the pancreas. It is only taken concurrently with insulin, and use can increase satiety and

lower blood glucose levels.

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Nutrition Therapy
The overall goal of nutrition therapy is to help people with diabetes make healthy food choices

and eat a varied diet that will lead to target blood glucose levels.

• For those using conventional, fixed insulin doses, day-to-day consistency in timing and

amount of food eaten is important. Patients using a basal-bolus approach with rapid-acting

insulin can adjust the dosage before meals based on the premeal glucose level and the

carbohydrate content of the meal.

• The emphasis of nutrition management in diabetes is placed on achieving glucose, lipid,

and BP goals and achieving weight loss if the patient is overweight or obese.

• People with diabetes are encouraged to follow the same healthy eating guidelines as those

without: eat whole grains, healthy fat, and lean protein; limit saturated and trans fats, and

increase plant-based foods.

• Encourage patients to frankly discuss the use of alcohol with their HCPs because its use

can make blood glucose harder to manage.

Exercise

• Regular, consistent exercise is an essential part of diabetes and prediabetes management.

Exercise increases insulin sensitivity and can have a direct effect on lowering blood glucose

levels.

• Patients who use insulin, sulfonylureas, or meglitinides are at increased risk for

hypoglycemia, especially if they exercise at the time of peak drug action or eat too little to

maintain target blood glucose levels. Teach them to exercise about 1 hour after a meal or have a

10- to 15-g carbohydrate snack and check their glucose before exercising.

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 Patients should delay activity if the blood glucose level is over 250 mg/dL and ketones are

present in the urine. If hyperglycemia is present without ketosis, it is not necessary to postpone

exercise.

Monitoring Blood Glucose

• Blood glucose monitoring (BGM) is a cornerstone of diabetes management. Using current

blood glucose readings, people can make informed self-management decisions about food,

exercise, and medication.

• The frequency of monitoring depends on several factors, including the patient’s glycemic

goals, the type of diabetes that the patient has, the patient’s ability to monitor independently, the

patient’s willingness to perform BGM, and cost. More people with diabetes are using continuous

glucose monitoring in addition to, or instead of, finger-stick blood glucose monitoring.

Pancreas Transplantation

• Pancreas transplantation can be used as a treatment option for people with type 1 diabetes.

Transplants are done for patients with end-stage kidney disease and who had or are having a

kidney transplant.

NURSING MANAGEMENT: DIABETES MELLITUS

• Nursing responsibilities for the patient receiving insulin include proper administration,

assessment of the patient’s response to insulin therapy, and teaching of the patient about

administration of, storage, adjustment to, and side effects of insulin, particularly recognition

and management of hypoglycemia.

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• Proper administration and assessment of the patient’s use of and response to oral and

noninsulin injectable agents, and teaching the patient and family about these drugs, are all part

of the nurse’s role.

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• The goals of diabetes self-management education are to guide the patient in becoming the

most active participant in his or her care, while matching the level of self-management to the

ability of the individual patient.

ACUTE COMPLICATIONS OF DIABETES MELLITUS

• Diabetes-related ketoacidosis (DKA) is a life-threatening condition caused by a profound

deficiency of insulin. It is characterized by hyperglycemia, ketosis, acidosis, and dehydration.

It is most likely to occur in people with type 1 diabetes.

• Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that can occur in

the patient with diabetes who is able to make enough insulin to prevent DKA but not enough to

prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.

• Hypoglycemia, or low blood glucose, occurs when there is too much insulin in proportion to

available glucose in the blood.

• Hypoglycemia is often related to a mismatch in the timing of food intake and the peak action of

insulin or oral glucose lowering agents that increase endogenous insulin secretion.

• A critical role of the nurse is the prompt recognition of hypoglycemia and starting the

appropriate treatment depending on the patient’s status.

CHRONIC COMPLICATIONS OF DIABETES MELLITUS

• Chronic complications primarily include end-organ disease from damage to blood vessels from

chronic hyperglycemia. These are divided into 2 categories: macrovascular complications and

microvascular complications.

• Macrovascular complications are diseases of the large and medium-sized blood vessels (heart,

peripheral vascular system, and brain) that occur with greater frequency and with an earlier

onset in people with diabetes.

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• Microvascular complications affect the tiny vessels of the eyes, kidneys, and nerves. They

result from several pathways, all in response to chronic hyperglycemia.

• Retinopathy refers to the process of microvascular damage in the back of the eyes because of

chronic hyperglycemia. There are 2 types: proliferative and nonproliferative retinopathy.

Because the earliest and most treatable stages cause no vision changes, teach persons with

diabetes to have an annual dilated eye examination.

• Nephropathy is a microvascular complication associated with damage to the small blood

vessels that supply the glomeruli of the kidneys. Teach patients to get screened annually for

albuminuria. A measurement of albumin-creatinine ratio from a urine specimen may also be

used to assess renal function.

• Neuropathy is nerve damage that occurs because of the metabolic derangements associated

with diabetes. The 2 major categories of diabetes-related neuropathy are sensory neuropathy,

which affects the peripheral nervous system, and autonomic neuropathy.

• The most common form of sensory neuropathy is distal symmetric neuropathy, which affects

the hands and/or feet bilaterally.

• Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemia

unawareness, delayed gastric emptying (gastroparesis), constipation, diarrhea, urinary

retention, and sexual dysfunction.

Complications of the Feet and Lower Extremities

• Foot complications are one of the most common causes of hospitalization in the person with

diabetes. Sensory neuropathy is a major risk factor for lower extremity amputation.

• Because of the loss of protective sensations, proper care of the feet in patients with diabetes is

critical to prevent infections.

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• Proper care of foot ulcers is critical to prevent amputations.

Skin Complications

• Up to two thirds of people with type 1 and type 2 diabetes develop diabetes-related skin

problems. Common problems include acanthosis nigricans, dermatopathy, and necrobiosis

lipoidica diabeticorum.

• Because skin is prone to injury, special care must be taken to protect it from injury and

ulceration.

Infection

• A person with diabetes is more susceptible to infections due to a defect in the mobilization of

inflammatory cells and impaired phagocytosis by neutrophils and monocytes.

• Antibiotic therapy for infections, which must be prompt and vigorous, has prevented infection

from being a major cause of death in patients with diabetes.

Psychosocial Considerations

• People with diabetes have increased rates of mental health disorders, particularly depression
and distress.

Assess patients for the signs and symptoms of depression and distress at each visit.

• Persons with type 1 diabetes, particularly young women, have an increased risk of developing

an eating disorder in comparison to people without diabetes. Open and collaborative

communication is critical for identifying these behaviors early. Use language that is person

centered, strengths based, and empowering.

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