DIABETES MELLITUS

PRESENTED BY-
DEEPANSHI MASIH
1ST YEAR [Link]. NURSING
ECON
INTRODUCTION

Diabetes mellitus is a serious health problem throughout the world, and

its prevalence is rapidly increasing. The long term complications associated
with diabetes can make it a devastating disease. Diabetes is the leading
cause of adult blindness, end stage renal disease, and non-traumatic
lower limb amputations. It is also major contributing factor to heart
disease and stroke.
 “Diabetes” comes from the Greek word for “siphon”, and implies that a
lot of urine is made.

 The second term “Mellitus” comes from the Latin word, "Mel” which
means “honey”, and was used because the urine was sweet.
 DEFINITION
 Diabetes mellitus (DM) is a group of disease characterized by high
levels of blood glucose resulting from defects in insulin production,
insulin action, or both.

 A disease in which the body’s ability to produce or respond to the

hormone insulin is impaired, resulting in abnormal metabolism of
carbohydrates and elevated levels of glucose in the blood.
 DIABETES IN INDIA

 According to the Indian Council of Medical Research-Indian Diabetes study (ICMR-

INDIAB), a national diabetes study, India currently has 63 million people with
diabetes.

 India represents the world’s second largest diabetes population after China.

 This is set to increase to over 100 million by 2030.

 The majority of people of people with diabetes (>90%) have Type II diabetes (T2DM).
 ETIOLOGY

 Current theories link the causes of diabetes, singly or in a

combination, to genetic, autoimmune, and environmental factors
(e.g., virus, obesity).

 Regardless of its causes, diabetes is primarily a disorder of glucose

metabolism related to absent or insufficient insulin supply and/or
poor utilization of the insulin that is available.
RISK FACTORS

NON MODIFIABLE MODIFIABLE

AGE- ABOVE
45 PRE-DIABETES

HEART AND BLOOD DISEASE

FAMILY HYPERTENSION
HISTORY
OBESITY

LOW HDL & HIGH TRIGLYCERIDES

 PHATHOPHYSIOLOGY
 Normal glucose and insulin metabolism

Insulin is prepared by beta cells in islets of

Langerhans of pancreas

Under normal condition

Insulin continuously released into the bloodstream with increase

Released when food is ingested

Insulin lowers blood glucose and facilitates a stable,

Normal range of glucose (70-110mg/dl)

Insulin promotes glucose transport from the blood stream across

The cell membrane to the cytoplasm

Cells breakdown glucose to make energy

Liver and muscles cells store excess glucose as glycogen

 The rise in plasma insulin after a meal inhibits gluconeogenesis, enhances fat
disposition of adipose tissue, and increase protein synthesis.

 Other hormones (glucagon, epinephrine, growth hormone and cortisol) work to

oppose the effects of insulin and are referred to as counterregulatory hormones.

 The counter regulatory hormones and insulin usually maintains blood glucose levels
within the normal range by regulating the release of glucose for energy during
food intake and period of fasting.
 TYPE 1 DM PATHOPHYSIOLOGY

Its autoimmune disorder

Caused by genetic predisposition and exposure to toxins

Body develops antibodies against insulin or the pancreatic beta cells producing insulin

Results in not enough insulin for a person to survive

Autoantibodies to the islet cells cause a reduction of normal function

Symptoms is rapid, initially seen with ketoacidosis

Sudden weight loss and polydipsia, polyuria, polyphagia

Patient may require insulin from outside source to sustain life

 TYPE 2 DM PATHOPHYSIOLOGY

Due to combination of inadequate insulin secretion and insulin resistance

Pancreas usually produces endogenous (self made) insulin

Body either does not produce enough or does not use insulin effectively or both

Insulin resistance, a condition which body tissues do not respond to the action of insulin

Because insulin receptors are unresponsive

Polydipsia, polyuria, polyphagia

 OTHER SEPECIFIC TYPES OF DIABETES

 PREDIABETES-: it is defined as impaired glucose tolerance, impaired fasting

glucose, or both. It is an intermediate stage between normal glucose homeostasis
and diabetes, in which the blood glucose levels are elevated but not high enough
to meet the diagnostic criteria for diabetes.

 GESTATIONAL DIABETES-: it develops during pregnancy. Women with

gestational diabetes have a higher risk for caesarean delivery, and their babies
have increased risk for perinatal death, birth injury, and neonatal complications.
Women who are at high risk for gestational diabetes are screened at the first
prenatal visit.
 CLINICAL MANIFESTATIONS
 TYPE 1 DM
 Because the onset of type 1 DM is rapid, the initial manifestations are usually
acute.
 the classic symptoms are-: polyuria, polydipsia and polyphagia.

 NUTRITION-METABOLIC-:Obesity, weight loss, thirst, hunger, nausea and

vomiting

 ELIMINATION-:Constipation or diarrhoea, frequent urination, bladder

infection.

 ACTIVITY-EXERCISE-:Muscle weakness, fatigue

 COGNITIVE-PERCEPTUAL-:Abdominal pain, headache, blurred vision,
numbness of tingling of extremities.

 COPING STRESS TOLERENCE-:Depression, irritability, apathy

 RESPIRATORY-:Rapid, deep respirations

 CARDIOVASCULAR-:Hypertension

 GASTROINTESTINAL-:Dry mouth, vomiting, fruity smell from the mouth

 INTEGUMETARY-:Dry skin, prolonged wound healing

 The clinical manifestations of type 2 DM are often asymptomatic.

 Patient may experience classic symptoms as type 1 DM including polyuria,

polydipsia and polyphagia.

 Other common manifestations associated with type 2 DM are-:

 Fatigue
 Recurrent infections
 Candida infections
 Prolonged wound healing
 Visual changes
 COMPLICATIONS
 ACUTE COMPILCATION OF DM

1. DIABETIC KETOACIDOSIS

2. HYPEROSMOLAR HYPERGLYCEMIC SYNDROME

3. HYPOGLYCEMIA

4. HYPOGLYCEMIA UNAWARENESS
 CHRONIC COMLPICATIONS OF DM
1. DIABETIC PERIPHERAL ANGIOPATHY

2. DIABETIC RETINOPATHY

3. NEPHROPATHY

4. NEUROPATHY

5. FEET AND LOWER EXTRIMITIES COMPLICATIONS

6. INTEGUMENTARY COMPLICATION

7. INFECTION

8. PSYCHOLOGICAL CONSIDERATIONS
 DIAGNOSTIC ASSESSMENT
 The diagnosis of diabetes mellitus is made using one of the following four
methods-:

1. A1C (elevated glucose or glycosylated haemoglobin) of 6.5% or higher.

2. Fasting plasma glucose levels greater than or equal to 126mg/dl.

3. Two-hour plasma glucose level greater than or equal to 200mg/dl, using a glucose
load of 75g.

4. In a patient with classic symptoms of hyperglycemia (polydipsia, polyuria,

unexplained weight loss), a random plasma glucose greater than or equal to
200mg/dl.
  DIAGNOSTIC ASSESSMENT-:

 History and physical examination

 Blood tests, including fasting blood glucose, postprandial blood glucose, A1C, lipid profile,
blood urea nitrogen, and serum creatinine, electrolytes.

 Urine for complete complete urinalysis, albuminuria, and acetone.

 Blood pressure

 ECG

 Dental examination

 Neurological examination

 Foot examination

 Dilated eye examination (funduscopic examination)

 Monitoring of weight
 MEDICAL MANAGEMENT
 The goal of diabetes managements is to reduce symptoms, promote wellbeing,
prevent acute complications related to hyper- and hypoglycaemia, and prevent
or delay the onset and progression of long term complication.

 These goals are most likely to be met when the patient is able to maintain
blood glucose levels as near to normal as possible.

 Diabetes is a chronic disease that require daily decisions about food intake,
blood glucose monitoring, medication and exercise.

 Nutritional therapy, drug therapy, exercise, and self-monitoring of blood

glucose are the tools used in the management of diabetes.
 The three major types of glucose-lowering agents used in the treatment
of diabetes are insulin, oral agents, and noninsulin injectable agents.

 All individual with type 1 diabetes require insulin.

 For some people with type 2 diabetes, a healthy eating plan, regular
physical activity, and maintenance of healthy body weight are sufficient
to attain optimal blood glucose level.
 PHARAMCOLOGICAL MANAGEMENT
 INSULIN

 Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet
specific metabolic needs. People with type 1 diabetes require exogenous insulin to
survive and often use multiple daily injections of insulin or continuous insulin infusion via
an insulin pump to adequately manage blood glucose levels. People with type 2 diabetes
may require exogenous insulin during periodic of severe stress such as illness or
surgery.

 TYPES OF INSULIN-: the insulin is derived from common bacteria (e.g., Escherichia coli) or
yeast cells using recombinant deoxyribonucleic acid technology.

 INSULIN REGIMENS-: the basal-bolus regimens is intensive or physiology insulin therapy,

consisting of multiple daily insulin injections together with frequent self-monitoring blood
glucose. The goal is to achieve a glucose level of 80 to 130 mg/dl before meals.
INSLULIN PREPARATION ONSET AND DURATION
RAPID ACTING ONSET-: 10-30 min
Lispro
DURATION-: 3-5 hr.
Aspart

Glulisine
SHORT ACTING ONSET-: 30min-1hr
Regular
DURATION-: 5-8hr
INTERMEDIATE ACTING ONSET-: 1.5-4 hr
NPH
DURATION-: 12-18hr
LONG ACTING ONSET-: 0.8-4 hr
Glargine
DURATION-: 16-24 hr
Detemir
INHALED INSULIN ONSET-: 12-15min
 ORAL AND NONINSULIN INJECTABLE AGENTS

 BIGUANIDES-: the most widely used oral diabetes agent is metformin. It is the
most effective first line treatment for type 2 diabetes.

 SULFONYLUREAS-: The primary action of the sulfonylureas is to increase insulin

production by the pancreas.

 MEGLITINIDES-: it increases insulin production by the pancreas.

 THIAZOLIDINEDIONES-: sometimes referred to as “insulin sensitizers”. They are

the most effective for people who have insulin resistance. These agents improve
insulin sensitivity, transport, and utilization at target tissues.
 SURGICAL MANAGEMENT
 BRIATRIC SURGERY-: it may be considered for patients with type 2 diabetes, especially if
the diabetes or associated co-morbidities are difficult to manage with lifestyle and drug
therapy.

 PANCREAS TRANSPLANTATION-: it can use as a treatment option for patients with type 1
diabetes. Usually it is done for patients who have end-stage renal disease and have or plan to
have a kidney transplant. Kidney and pancreas transplants are often performed together, or a
pancreas mat be transplanted after a kidney transplant.

 PANCREATIC ISLET CELL TRANSPLANTATION-: it is an another potential treatment

measure. During this procedure, the islets are harvested from the pancreas of a deceased
organ donor. The islet are infused via a catheter through the upper abdomen into the portal
vein of the liver.
 NURSING MANAGEMENT
 The overall goal is for the patient with diabetes mellitus to-:
1. Engage in self-care behaviour to actively manage his or her diabetes.

2. Experience few or no hyperglycemia or hypoglycaemia emergencies.

3. Maintain blood glucose levels at normal or near-normal levels.

4. Prevent or minimize chronic complication related to diabetes.

5. Adjust lifestyle to accommodate the diabetes plan with a minimum of stress

•THEORY APPLICATION

OREM’S THEORY

COMPONENTS PROBLEM NURSING

DIAGNOSIS
AIR    
NUTRITION
Obesity Imbalance nutrition, more than body
requirement related to excess body weight mass

WATER
Frequent urination Fluid volume deficient related to osmotic
diuresis

Secondary to polyuria and dehydration.

ACTIVITY AND REST
Insomnia Disturbed sleep pattern related to anxiety
secondary to unable to cope diabetic
management plans.
SOCIAL INTERACTION
Irritability and anxiety Anxiety related to loss of control, fear of
inability to manage diabetes, fear of diabetes
complications.
PREVENTION OF
injury and delayed Risk for infection related to high glucose levels
HAZARDS
wound healing secondary to reduction in leukocyte function.
PROMOTION OF    
 NURSING DIAGNOSIS
 Risk for unstable blood glucose related to inadequate blood glucose monitoring as
evidence by the signs of hyperglycemia.
 Risk for disturbed sensory perception related to diminished or impaired response to
stimuli.
 Ineffective therapeutic regimen management related to unsatisfactory meeting of
specific health goals secondary to lack of knowledge about diabetes and its
management.
 Risk for injury related to immune system deficit secondary to lack of self-care.
 Risk for impaired skin integrity related to decreased circulation and sensation
secondary to arterial obstruction.
 HEALTH EDUCATION
 Instructions for patients with diabetes mellitus

1. BLOOD GLUCOSE
 Monitor the blood glucose at home and keep records results in a log.

 Take insulin as prescribed.

 Keep adequate supply of insulin on hand at all times.

 Obtain A1C blood test every 3-6 months as an indicator of long term blood glucose levels.

 Be aware of symptoms of hypoglycaemia and hyperglycemia.

1. EXERCISE
 Learn how to exercise that an affect your blood glucose levels.

1. FOOD
 Make healthy food choices most of the time and eat regular meals at regular
times.

 Choose foods in low saturated and trans fat. Know the pateint cholesterol level.

 Limit the amount of alcohol.

 Limit regular soda and fruit juice.

 RESEARCH INPUT

 A study was conducted in 2017 in Brazil by Carl Regina, Ph.D. professor of

department of general and specialized nursing, and Maria Lucia, associate
professor of department of general and specialized nursing, WHO support centre
for nursing research development. The objective was to identify nursing diagnosis
in people with diabetes mellitus according to Orem’s theory of self-care. The
sample consisted of 31 people with diabetes mellitus who received care. Data
was collected through health assessment and interviews. Nursing diagnosis were
made according to NANDA-I Taxonomy II, using critical thinking described by
Risner. Among 37 nursing diagnosis, 3 of them were present in more than 50% of
the participants: ineffective management of therapeutic regimen (67%),
knowledge deficit (51%), and impaired skin integrity (51%). 18 nursing diagnosis
were related to Orem’s requirements for universal self-care.
 CONCLUSION

 Diabetes mellitus is considered to be a major health problem that is predicted

to turn into a global epidemic. In developing countries, the number of people
with diabetic gradually increasing day by day; as well as complication like
diabetic retinopathy will continue to rise. It is significant public health
problem all over the world. Adequate treatment of the risk indicators might
prevent and reduce the burden of these diseases and improve the quality of
health care services.
BIBLIOGRAPHY

 Burner and suddarths, textbook of medical surgical nursing

Volume 2; 13th edition
Wolters Kluwer publication
Page no. 1416-1461

 Lewis, medical surgical nursing

Volume 2; 3rd edition
ELSEVIER publication
Page no.1077-1109
 Marianne baird, manual of critical care nursing
7th edition
ELSEVIER publication
Page no. 551
 [Link]
 [Link]
THANK YOU