Diabetes Mellitus

is a group of metabolic disorders characterized by elevated levels of blood glucose

(hyperglycemia) resulting from defects in insulin production or secretion, decreased cellular response to
insulin or both. Because cells cannot use glucose, fats and even proteins are broken down and used to
meet the energy requirements of the body. As a result, body weight begins to decline. Loss of body
proteins leads to a decreased ability to fight infections, so diabetics must be careful with their hygiene
and in caring for even small cuts and bruises.

TYPES OF DIABETES MELLITUS

TYPE I DIABETES MELLITUS TYPE 1

Diabetes Mellitus also called Insulin Dependent Diabetes Mellitus starts in childhood or adolescence is
usually more severe than that beginning in middle or old age. Patients have little or no ability to produce
the hormone and are entirely dependent on insulin injections for survival.

TYPE II DIABETES MELLITUS Type 2

Diabetes Mellitus also called adult-onset diabetes or Noninsulin Dependent Diabetes Mellitus. 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 mellitus because of its slow onset and can usually be controlled
with diet and oral medication. 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 can
begin so gradually that a person may not know that he has it.

GESTATIONAL DIABETES MELLITUS

Gestational Diabetes Mellitus is any degree of glucose intolerance with its onset during pregnancy.
Hyperglycemia develops during pregnancy because of the secretion of placental hormones, which
causes insulin resistance. After delivery, blood glucose levels in women with Gestational diabetes
mellitus usually return to normal. However, many women who have had Gestational diabetes mellitus
develop type 2 diabetes later in life. Therefore, a woman who has Gestational diabetes mellitus should
be counseled to maintain her ideal body weight and to exercise regularly to reduce her risk for type 2
diabetes.

MANAGEMENT OF DIABETES

TYPE I Diabetes Mellitus – Insulin

TYPE II Diabetes Mellitus – Diet, Exercise, OHA (Oral Hypoglycemic Agent)

Gestational Diabetes Mellitus – Insulin, Diet, Exercise

DIABETIC DIET

 PURPOSE: Maintain blood glucose as near as normal as possible, delay or prevent onset of
diabetic complications.
 FOODS ALLOWED:
 Choose foods with low glucose index compose of:
a. 45-55% carbohydrates
b. 30-35% fats
c. 10-25% protein
 Coffee, tea, broth, spices and flavorings can be used as desired
 Exchange groups include milk, vegetables, fruits, bread/starch, meat (divided in lean,
medium fat, and high fat), and fat exchanges.
 The number of exchanges allowed from each group is dependent on the total number
of calories allowed
 Non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight
diabetics.

 FOODS TO BE AVOIDED
 Concentrated sweets or regular soft drinks

EXERCISE

 PURPOSE
 Helps burn fats which in excess may lead to obesity that can cause serious
complications
 Not allowed during period of stress (illness or surgery).

INSULIN

Insulin increases glucose transport into cells and promotes conversion of glucose to glycogen,
decreasing serum glucose levels. Primarily acts in the liver, muscle, adipose tissue by attaching to
receptors on cellular membranes and facilitating transport of glucose, potassium and magnesium.
Hormone secreted by the alpha cells of the islets of langerhans in the pancreas. Increase blood glucose
by stimulating glycogenolysis in the liver.

 Given subcutaneously, intramuscularly or intravenously.

 DO’S AND DON’T’S IN ADMINISTERING INSULIN

o Check the expiration date.
o Never aspirate.
o Never massage the injection site.
o Never inject a cold insulin.
o Rotate the injection site.
ORAL HYPOGLYCEMIC AGENT

If normal blood glucose levels are not achieved after 2-3 months of lifestyle modifications,
treatment with an oral antihyperglycemic drug is often prescribed. However, the patient should be
clearly advised that the ability of any drug therapy to improve the health of any diabetic patient is aided
by appropriate changes in diet and activity level.

RISK FACTORS OF TYPE II DM

 OBESITY
Obesity is a medical condition in which excess body part has occumulated to the extent
that it may have an adverse effect on health, leading to reduce life expectancy. Body
mass index, which compares weight and height, is used to define a person as overweight
when their BMI is between 25 kg/m2 and 30kg/m2 and obese when it is greater than 30
kg/m2 . The primary treatment for obesity is dieting and physical exercise. If this fails,
antiobesity drugs may be taken to reduce appetite or inhibit fat absorption.

 IMPAIRED GLUCOSE TOLERANCE

Several factors have contributed to induce the impairment of glucose tolerance in the
elderly. Especially, changes of body composition with aging, the loss of skeletal muscle
mass and relatively increased fat tissues, could occur the insulin resistance state. Such
state would be well known to accompany with diabetes mellitus and hypertension.
Therefore, the treatment of hypertension with diabetes in the elderly would be very
important to prevent not only microangiopathy but also macroangiopathy. The optimal
blood pressure levels to reduce hypertension – related morbidity and mortality in
diabetic elderly have been proposed 130/85. The first step therapy in this case would be
recommended calcium channel blocker, angiotensin converting enzyme inhibitor, and
angiotensin receptor blocker. In addition, comprehensive geriatric assessment must be
important to maintain drug compliance for well controlled blood pressure levels.

 GENETICS/HEREDITARY
In a study of 200 adults with type 2 diabetes, about 2/3 reported atleast one close
relative with diabetes and nearly 50 % had atleast two relatives with the disease. In
particular, people whos mother had diabetes where twice as likely to get the disease as
those whos father had diabetes.

 RACE
Diabetes occurs more often in Hispanic/Latino Americans, African-Americans, Native
Americans, Asian Americans, Pacific Islanders, and Alaska Natives.

 HYPERTENSION
Hypertension, or high blood pressure, is a major risk factor of diabetes. High blood
pressure is generally defined as 140/90 mmHg or higher. Low levels of HDL ( good
cholesterol) and high triglyceride levels also put you at risk.
  SEDENTARY LIFESTYLE
Being inactive – exercising fewer than 3 times a week makes you more likely to develop
diabetes.

 AGE
Some doctors advise anyone over 45 to be screened for diabetes. That’s because
increasing age puts you at higher risk of developing type 2 dibetes. It’s important to
remember, though, that people at any age can develop diabetes.

PREVENTION

 Maintain body weight and prevent obesity through proper nutrition and physical
activity/exercise.
 Encourage proper nutrition – eat more dietary fiber, reduce salt and fat intake, avoid
simple sugars like cakes and pastries; avoid junk foods.
 Promote regular physical activity and exercise to prevent obesity,hypercholesterolimia,
and enhance insulin action in the body.
 Advise smoking cessation for active smokers and prevent exposure to second hand
smoke. Smoking among diabetes increases risk for heart attack and stroke.

DIABETIC KETOACIDOSIS

Ketoacidosis is a serious condition that can lead to diabetic coma or even death. When the cells
don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces
ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn’t
have enough insulin. Ketoacidosis may happen to anyone with diabetes, though it is rare in people with
Type 2.

CLINICAL MANIFESTATIONS EARLY SYMPTOMS INCLUDE:

 Thirst or a very dry mouth

 Frequent urination
 High blood glucose levels
 High levels of ketones in the urine
 Polyphagia

OTHER SYMPTOMS APPEAR

 Constantly feeling tired

 Dry or flushed skin
 Nausea, vomiting or abdominal pain
 Short, deep breaths
 Fruity odor or breath
 Confusion
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS)

Hyperglycemic Hyperosmolar Nonketotic Syndrome is a serious condition most frequently seen

in older persons. HHNS can happen in either type 1 or type 2 diabetes, but it occurs more often in
people with type 2. In HHNS, blood sugar levels rise, and your body tries to get rid of the excess sugar by
passing it into your urine. If HHNS continues, the severe dehydration will lead to seizures, coma and
eventually death.

CLINICAL MANIFESTATIONS

 Blood sugar level over 600 mg/dl

 Dry, parched mouth
 Extreme thirst
 Weakness
 Weak, rapid pulse
 Polyuria
 Polydipsia
 Polyphagia

NEPHROPATHY

Kidneys are remarkable organs. Inside them are millions of tiny blood vessels that act as filters.
Their job is to remove waste products form the blood. Diabetes can damage the kidneys and cause them
to fail. High levels of blood sugars make kidneys filter too much blood. At this extra work is hard on the
filters. After many years, they start to leak and useful protein is lost in the urine.

CLINICAL MANIFESTATIONS

The kidneys work hard to make up for the failing capillaries so kidney disease produces no
symptoms until most all functions are gone. The first symptom of kidney disease is often fluid build up.
Other symptoms of kidney disease include:

 Loss of sleep
 Poor appetite
 Weakness
 Microalbuminuria

RETINOPATHY

Retinopathy is a damage to the retina caused by complications of diabetes mellitus, which can
eventually lead to blindness. It is an ocular manifestation of systematic disease which affects up to 80%
of all patients who have had diabetes for 10 years or more.

CLINICAL MANIFESTATIONS

 Blurring of vision
 Few specks of blood
 Floating spots
HYPOGLYCEMIA

Hypoglycemia, sometimes called an insulin reaction, can happen even during those times where
you’re doing all you can to manage your diabetes.

CLINICAL MANIFESTATIOS

 Shakiness
 Dizziness
 Sweating
 Hunger
 Pale skin color
 Clumsy or jerky movements
 Confusion

NEUROPATHY

Neuropathy affects all peripheral nerves: pain fibers, motor neurons, autonomic nerves. It
therefore necessarily can affect all organs and systems since all are innervated

CLINICAL MANIFESTATIONS

 Numbness and tingling of extremities

 Decreased or loss of sensation to a body part
 Muscle weakness
 Difficulty swallowing
 Speech impairment
 Vision changes
 Urinary incontinence

MACROVASCULAR DISEASES

Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels
supplying the brain. Hypertension is the most important cause; it damages the blood vessel lining,
endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process
which is not always complete and perfect. Sustained hypertension permanently changes the
architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to
fluctuations in blood pressure. A fall in blood pressure during sleep can then lead to a marked reduction
in blood flow in the narrowed blood vessels causing ischemic stroke in the morning. Conversely, a
sudden rise in blood pressure due to excitation during the daytime can cause tearing of the blood
vessels resulting in intracranial hemorrhage. Cerebrovascular disease primarily affects people who are
elderly or have a history of diabetes, smoking, or ischemic heart disease. Myocardial infarction (MI) or
acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood
supply to part of the heart, causing some heart cells to die. This is most commonly due to occlusion
(blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an
unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an
artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a
sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).
PERIPHERAL VASCULAR DISEASE

In peripheral vascular disease, a diabetic client can develop arterial occlusion and
thrombosis that can lead to gangrene but this can be developed years after you have been
diagnosed of diabetes mellitus and not properly treating it. Both the types of diabetes mellitus
have a risk to develop this type of disease.

CLINICAL MANIFESTATIONS

 Tingling sensation of affected area

 Numbness / loss of sensation
 Pale skin color

DIAGNOSTIC EXAMS

 Random blood glucose test (RBS)

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 200mg/dl (11.1mmol/L)
or higher in persons who have symptoms of high blood glucose suggest a diagnosis of diabetes.
 Fasting blood glucose test (FBS)

Fasting blood glucose testing involves measuring blood glucose after not eating or
drinking for 8 to 12 hours (usually overnight).

 Hemoglobin A1C test (HbA1c)

The A1C blood test measures the average blood glucose level during the past 2 to 3
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. The test is done
by taking a small sample of blood from a vein or fingertip.

 Oral glucose tolerance test (OGTT)

Oral glucose tolerance testing 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.

NURSING DIAGNOSIS 

 Risk for fluid volume deficit related to frequent urination.

Goal: Provision of fluid balance. Demonstrate adequate hydration as evidenced by stable vital
signs palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate
urinary output.
 Risk for infection related to insufficient knowledge on Proper wound care.
Goal: Have knowledge on proper wound care. Identify interventions to prevent or reduce risk of
infection. Demonstrate techniques, lifestyle changes to prevent development of infection.
 Imbalanced Nutrition: less than body requirements related to inability to utilize nutrients.
Goal: Maintain normal nutritional status. Demonstrate stabilized weight or gain toward usually
or desired range.
Nursing Care Plan

 NURSING DIAGNOSIS: Risk for fluid volume deficit related to frequent urination.
Goal: Provision of fluid balance. Demonstrate adequate hydration as evidenced by stable vital
signs, palpable peripheral pulses, good skin turgor and capillary refill, individuality appropriate
urinary output.
 NURSING DIAGNOSIS: Imbalanced Nutrition: less than body requirements related to inability to
utilize nutrients.
Goal: Maintain normal nutritional status. Demonstrate stabilized weight or gain toward
usual/desired range.
 NURSING DIAGNOSIS: Risk for infection related to insufficient knowledge on proper wound
care.
Goal: Have knowledge on proper wound care. Identify interventions to prevent or reduce risk of
infection. Demonstrate techniques, lifestyle changes to prevent development of infection

EVALUATION

After an exposure to the community, the client:

 Participated in planning the activities and started showing operation in every task he makes.
 The client will be able to gain knowledge about possible complications of the disease.
 Demonstrated compliance with dietary restrictions and to take his medication as scheduled and
how to manage any side effects of therapy.
 Experienced increase comfort.

After an exposure to the community, the students:

 We, the students realize the value of teamwork and cooperation as an integral part and the
smooth flow of our work in the area fostering unity thereby leading us to effective nursing care
provider and satisfaction as well.
 We are able to identify the problem as well as discussing its causes, manifestation, treatment
and prevention of the possible complications.
 To know the common disease found in the community.
 Assist the client in developing ways to incorporate the therapeutic plan into their lives rather
than merely giving client list of instruction.
RECOMMENDATION

 Have a regular check-up and follow therapeutic regimen.

 Provide an extra effort in managing disease.
 Advise to avoid stressors that trigger to disease.
 Instruct the client on how to promote and maintain nutritional status.
 Advise the client to avoid alcoholic beverages or to limit his intake because alcohol interference
with the utilization of essential nutrients.