DIABETES

is a group of metabolic diseases characterized by elevated of glucose in the

blood (hyperglycemia) resulting from defects in insulin and insulin action.
Major sources of this glucose are absorption of ingested food in
gastrointestinal tract and formation of glucose by the liver from food substance.
Insulin
a hormone produced by the pancreas, controls the level of glucose in the
blood by regulating the production and storage of glucose

In diabetic state, the cells may stop responding to insulin or the pancreas
may stop producing insulin intirely.

Leads to hyperglycemia, which may result in acute metabolic complication

sush as:

a. diabetic ketoacidosis (DKA)

b. hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

Long-term effects of hyperglycemic contribute to:

1. macro vascular complication (coronary artery disease, cerebrovascular

disease and peripheral vascular disease)
2. chronic macrivascular complication (kidney and eye disease)
3. neuropathic complication (disease of the nerve)

Primary Goal of treatment for patients with diabetes

♦ controlling blood glucose level

♦ preventing acute
♦ long term complication

CLASSIFICATION OF DIABETES

Several different types of DM

a. cause
b. clinical course
c. treatment

Major classifications of diabetes are:

 a. type 1 diabetes (previously referred to as insulin-independent
diabetes mellitus) IDDM

b. type 2 diabetes (previously referred to as non-insulin-independent

diabetes mellitus) NIDDM

c. gestational diabetes mellitus

d. DM with others conditions or syndrome

OVERVIEW

terms “insulin-dependent diabetes” and “non-insulin-dependent diabetes” are

no longer used because they have resulted in classification of patients on the
basis of the treatment of their diabetes rather than the underlying etiology.
Approximately 5% to 10% of people with diabetes have type 1 diabetes,
which the insulin- producing pancreatic beta cells are destroyed by an
autoimmune process.

♦ type 1 diabetes is characterized by an acute onset, usually before

age 30

 pproximately 90% to 95% of people with diabetes have type 2 diabetes,

a
which result from decreased sensitivity to insulin (called insulin resistance) and
impaired beta cell functioning resulting in decreased insulin production.

• type 2 diabetes is first treated with diet and exersice

• type 2 diabetes occurs more among people who are older
than 3o years and obese.

 orderline diabetes is classified as impaired glucose tolerance (IGT) or

b
impaired fasting glucose (IFG) and refers to a condition in which blood glucose
level fall between normal levels and levels considered diagnostic for diabetes.

Risk Factors for Diabetes Mellitus

1. Family history of diabetes

2. Obesity
3. Race/Ethnicity
4. Age
 5. Previously independent impaired fasting glucose or impaired glucose
tolerance
6. Hypertension
7. HDL cholesterol level or triglyceride level
8. History of gestational diabetes or delivery of babies over 9 lbs.

PHYSIOLOGY AND PATHOPHYSIOLOGY OF DIABETES

insulin is secreted by beta cells, which are one of four types of cells in the
islets of Langerhans in the pancreas.
Insulin is an anabolic, or storage, hormone.
Insulin secretion increases and moves glucose from the blood into muscle,
liver, and fat cells, when the person eats a meal.
In those cells, insulin:

1. transports and metabolize glucose for energy

2. stimulates storage of glucose in the liver and muscle
3. signals the liver to stop the release of glucose
4. enhances storage of dietary fat in adipose tissue
5. accelerates transport of animo acids into cells

insulin also inhibits the breakdown of stored glucose, protein, and fat.

Classification of Diabetes Mellitus and Related Glucose Intolerances

Current Classification Previous Classification Characteristics and
Implication
Type 1 Juvenile diabetes Onset any age, but usually
Juvenile-onset diabetes young (<30yrs).
Ketosis-prone diabetes Usually thin at diagnostic;
Brittle diabetes with recent weight loss.
Insulin-dependent diabetes Etiology includes genetics,
mellitus(IDDM) immunologic, or
environmental factors.
Often have islet cell
antibiotics.
Little or no endogenous
insulin.
Need insulin to reserve life
Ketosis-prone when insulin
absent.
Acute complication of
hyperglycemia:diabetics
 ketoacidosis.
Type 2 Adult-onset diabetes Onset any age, usually
Maturity-onset diabetes over 30 years.
Ketosis-resistant diabetes Usually obese at diagnose
Stable diabetes Causes include obesity,
Non-insulin-independent heredity, or environmental
diabetes (NIDDM) factors.
No islet cell antibodies
Decrease in endogenous
insulin, or increased with
insulin resistance.
Moat patients can control
blood glucose through
weight loss if obese.
Oral antidiabetes agents
may improve blood glucose
levels if dietary modification
and exercise are
unsuccessful.
May need insulin on a
short- or long-term basis to
prevent hyperglycemia.
Ketosis rare, except in
stress or infection.
Acute complication:
hyperglycemic
hyperosmolar nonketonic
syndrome.
Diabetes mellitus Secondary diabetes Accompanied by condition
associated with other known or suspected to
conditions or syndrome cause the disease:
pancreatic diseases,
hormonal abnormalities,
medications such as
corticosteroids and
estrogen-containing
preparation.
Depending on the ability of
the pancreas to produces
insulin, the patient may
require treatment with oral
antidiabetes agents or
insulin.
Gestational diabetes Gestational diabetes Onset during pregnancy,
 usually in the second or
third trimester
Due to hormones secreted
by the placenta, which
inhibit the action of insulin.
Above-normal risk for
perinatal complication,
especially macrosomia.
Treatment with diet and if
needed insulin to strictly
maintain normal blood
glucose level.
Occurs in about 2%-5% of
all pregnancies.
Glucose intolerance
transitory but may recur:

• in subsequent pregnancies
• 30%-40% will develop overt
diabetes within 10 years

Risk factors include obesity,

age older than 30years,
family history of diabetes,
previous large babies.
Screening tests should be
performed on all pregnant
women between 24 and 28
wks gestation.
Oral glucose tolerated test
Impaired glucose Borderline diabetes value between 140 mg/dL
Intolerance Latent diabetes and 200 mg/dL.
Chemical diabetes Impaired fasting glucose is
Subclinical diabetes defined as a fasting plasma
Asymptomatic diabetes glucose between 110
mg/dL and 126 mg/dL.
29% eventually develop
diabetes
Above-normal susceptibility
to atherosclerosis disease.
Renal and retinal
complication usually not
significant.
May be obese or

Prediabetes Previous abnormality of
glucose tolerated
Prediabetes Potential abnormality of
glucose tolerated
nonobese; obese should
reduce weight.
Should be screened for
diabetes periodically.
Current normal glucose
metabolism.
Previous history of
hyperglycemia
Periodic blood glucose
screening after age 40 if
there is a family history of
diabetes or if symptomatic.
Encourage ideal body
weight, because loss of 10-
15 lbs may improve
glycemic control.
No history of glucose
intolerance.
Increased risk of diabetes
if:

• positive family history

• obesity
• mother of babies over 9lbs
at birth

Screening and weight

advice as in PrevAGT

CLINICAL MANIFESTATION

1. 3P’s – polyuria, polydipsia and polyphagia

2. Fatigue
3. Weakness
4. Sudden vision changes
5. Tingling or numbness in hands or feet
6. Dry skin
7. Skin lesions or wounds slowly to heal
8. Recurrent infections
9. Onset of type 1 diabetes – sudden weight loss, nausea, vomiting.
10. Abdominal pain – if DKA developed.
 ASSESSMENT AND DIAGNOSTIC FINDING

Criteria for the Diagnostic of Diabetes Mellitus

1. Symptoms of diabetes plus casual plasma glucose concentration equal to
or greater than 200 mg/dL. Casual is defined as any time of day without
regard to time since last meal. The classic symptoms of diabetes include
polyuria, polydipsia and unexplained weight loss.
2. Fasting plasma glucose greater than or equal to 126 mg/dL. Fasting is
defined as no caloric intake for at least 8 hours.

3. 2-hours postload glucose equal to or greater than 200 mg/dL during an

oral glucose tolerated test.

ASSESSMENT

1. history
2. physical examination
3. laboratory examination
4. need for referral

MANAGEMENT

Goal:

1. to normalize insulin activity

2. blood glucose levels to reduce the development of vascular and
nauropathic complication

1. Nutritional Management

Goals:

a. Providing all the essential food constituents necessary for optimal

nutrition.
b. Meeting energy
c. Achieving wide daily fluctuations in blood glucose levels, with blood
glucose levels as close to normal as is safe and practical to prevent or
reduce the risk for complication.
d. Decreasing serum lipid levels, if elevated, to reduce the risk for
macrovascular disease.
• Meal planning and related teaching
o caloric requirements
o caloric distribution
 carbohydrates
 fats
 fiber
o food classification systems
 exchanges lists
 food guide pyramid
 glycemic index
• Other Dietary concerns
o Alcohol consumption
o Sweetness
o Misleading food lebels

2. Exercise

• Benefits
• Exercise precaution

o General Precautions for Exercise in Diabetes:

a. Use proper foor wear and, if appropriate, other protective
equipment.
b. Avoid exercise in extreme heat or cold
c. Inspect feet daily after exercise
d. Avoid exercise during after periods of poor metabolic control.

• Exercise recommendations

3. Monitoring Glucose levels and Ketones

 lood glucose is monitoring is cornerstone of diabetes

b
management and self-monitoring of blood glucose (SMBG) level by patients has
dramatically altered diabetes care.

• Advantages and disadvantages of SMBG system

o common sources of error include:

1. Improper application of food

2. Improper meter cleaning and maintenance
3. Damage to the reagent strips

♦ Candidates for SMBG

♦ Unstable diabetes
 ♦ A tendency for severe ketosis or hypoglycemia
♦ Hypoglycemia without warning symptoms
♦ Frequency of SMBG
♦ Responding to SMBG results
♦ Glycosylated hemoglobin

Glycosylated hemoglobin = (referred to as HgbA or A1C) is a blood test

that reflects average blood glucose levels over a period of approximately 2
to 3 months.

♦ Urine testing for glucose

Disadvantages of urine testing include the following:

♦ Result does not accurately reflect the blood glucose level at the time of the
rest.
♦ The renal threshold foe glucose is 180-200 mg/dL, for above target blood
glucose levels.
♦ Hypoglycemia cannot be detected because a “negative” urine glucose
result may occur when the blood glucose leel ranges from 0-180 mg/dl or
higher.
♦ Patients may have a false of being in good control when results are
always negative.
♦ Various medications may interfere with the test result.
♦ In elderly patients and patients with kidney disease, the renal threshold is
raised, thus the false negative may occur at dangerously elevated glucose
levels.

• Testing for ketones

4. Pharmacology therapy

♦ Insulin Therapy and Insulin Preparations

♦ Time course of action
♦ Species (source)
♦ Manufacturer
♦ Insulin Regimens
♦ Conventional regimens
♦ Intensive regimens
♦ Complication of insulin therapy
♦ Local allergic reactions
♦ Systemic allergic reactions
♦ Insulin resistance
 ♦ Insulin lipodystrophy
♦ Morning hyperglycemia
♦ Alterative methods of insulin delivery
♦ Insulin pens
♦ Jet injections
♦ Insulin pumps
♦ Implantable and inhalant insulin delivery
♦ Transplantation of pancreatic cells
♦ Oral Antidiabetes Agents
♦ First-Generation Sulfonylureas
♦ acetohexamide (Dymelor)
♦ chlorpropamide (Diabinese)
♦ tolazamide (Tolinase)
♦ talbutamide (Orinase)
♦ Second-Genaration Sulfonylureas
♦ glipizide (Glucatrol)
♦ glipizide (Glucatrol XL)
♦ glyburide (Micronase)
♦ glimepiride (Amaryl)
♦ Biguanides
♦ metformin (Glucophage+GlucosephageXL)
♦ metformin with glyburine (Glucovance)
♦ Alpha Glucosidase Inhibitors
♦ Acarbose (Precose)
♦ Thiazolidinediones
♦ Pioglitazone (actos)
♦ Rosiglitazone (Avandia)
♦ Meglitinides
♦ Repaglinide (Prandin)
♦ Nateglinide (Starix)
♦ General Considerations for Oral Agents

NURSING MANAGEMENT

1. Education
2. Developing a Diabetes Teaching Plan

o Organizing Information
 Teaching Survival Skills
• Outline of survival information include:
o 1. Simple pathophysiology
 a. Basic definition of diabetes
b. Normal blood glucose ranges and target blood glucose levels.
c. Effects of insulin and exercise
d. Effects of food and stress, including illness and infections
e. Basic treatment approaches
2. Treatment modalities
a. Administration of insulin and oral antidiabetes medications
b. Diet information
c. Monitoring of blood glucose and ketones
3. Recognition, treatment, and prevention of acutr complications
a. Hypoglycemia
b. Hyperglycemia
4. Pragmatic information
a. Where to buy and store insulin, syringes and glucose monitoring
supplies
b. When and how to reach the physician

 Planning in Depth and Continuing Education

• Preventive measures include:
o Foot care
o Eye care
o General hygiene
o Risk factor management
o Assessment Readiness to Learn
o Determining Teaching Methods

3. Implementing The Plan

 Teaching Experienced Diabetic Patients

 Teaching Patients to Self-Administer Insulin
 Storing insulin
 Selecting syringes
 Preparing the injection: Mixing insulin
 Withdrawing insulin
 Selecting and Rotating the injection site
 Preparing the skin
 Injecting the needle
 Promoting home and community-based care
• Teaching patients self-care
♦ The following approaches by the nurse are help for promoting self-care
management skills:
 Address any underlying factors that may affect diabetic control.

Simply the treatment regimen if it is too difficult for the patient to follow.
  Adjust the treatment regimen to meet patient’s request.
 Establish a specific plan or contract with the patients with simple, measurable
goals.
 Provide positive reinforcement of self-care behaviors performed instead of
focusing on behaviors that were neglected.
 Help the patients to identify personal motivating factors rather than focusing on
wanting to please the doctors or nurse.
 Encourage the patients to pursue life goals and interest: discourage an undue
focus on diabetes.
 Continuing Care

ACUTE COMPLICATION OF DIABETES

1. Hypoglycemia (insulin reactions)

hypoglycemia (abnormally low blood glucose level) occurs when the blood
glucose falls to less than 50 to 60 mg/dL.
It caused by too much insulin or oral hypoglycemic agents, too little food, or
excessive physical activity.
May occur at any time of the day or night and often occurs before meals; if
meals are delayed or snacks are omitted.

Clinical Manifestations

• Mild hypoglycemia
• Blood glucose levels falls
• Sympathetic nervous stystem is stimulated
• Resulting in a surge of epinephrine and norepinephrine
• Causes symptoms sush as sweating, tremor, tachycardia, palpitation, nervouaness
and hunger
• Moderate hypoglycemia
• Fall in blood glucose level deprives the brain cells of needed for functioning.
• Signs of impaired function of the CNS may include inability to concentrate,
headache, lightheadedness, confusion, memory lapses, numbness of the lips and
tongue, slurred speech impaired coordination, emotional changes, irrational or
combative behavior, double vision and drowsiness.
• Severe hypoglycemia
• CNS function is so impaired that the patient needs the assistance of another person
for treatment of hypoglycemia.
• Symptoms may include disoriented behavior, seizures, difficulty arousing from sleep,
or loss of consciousness.

Assessment and Diagnostic Finding

Symptoms can occur suddenly and unexpectedly

Patients who have usually a blood glucose level in the hyperglycemic range
(eg. 200s or greater) may feel hypoglycemic symptoms when their blood glucose
quickly drops to 120mg/dL or less.
Patients who frequently have a glucose level in the low range of normal be
symptomatic when the blood glucose slowly falls to less than 50mg/dL
To altered hypoglycemic symptoms is a decreased hormonal response to
hypoglycemia
Severe CNS impairment patients perform SMBG frequently.

Management

t he usual recommended is for 15g of a fast-acting concentrated source of

carbohydrate such as the following, given orally,
o three or four commercially prepared glucose tablets
o 4 to 6oz of fruit or regular soda
o 6 to 10 life savers or other hand candies
o 2 to 3 teaspoons of sugar or honey

1. Teaching Patients
2. Initiating Emergency Measures
3. Promoting Home and Community-Based Care

o Teaching patients self care

2. Diabetic Ketoacidosis

caused by an absence or markedly inadequate amount of insulin

disorder in the metabolism of carbohydrate, protein and fat
3 main clinical features:
o Hyperglycemia(300-800mg/dL)
o Dehydration (6.5 L water loss) and electrolyte loss (400-500meq of
Na+,K+ and C1-24 hr period)
o Acidosis (low serum HCO3=0-15meq/L; low pH=6.8-7.3)
3 main causes:
 o Decreased or missed dose of insulin
o Illness or infection
o Undiagnosed and untreated diabetes

Clinical Manifestation

 yperglycemia leads to polyuria, polydipsia, blurred vision, weakness, and

h
headache
intravascular volume depletion-orthostatic hypotension
volume depletion leads to trank hypotension with a weak rapid pulse
ketosis and acidosis of DKA lead to GI symptoms such as anorexia, nausea,
vomiting and abdominal pain.
Acute breath- elevated ketone levels
Hyperventilation

Assessment and Diagnostic Findings

blood glucose levels may vary from 300-800 mg/dl

severity of DKA is not necessarily related to the blood glucose level
patient mat have severe acidosis with modestly elevated blood glucose levels
blood glucose levels of 400-500mg/dl have no evidence of DKA
Evidence of ketoacidosis is reflecting in low serum bicarbonate and low pH
values.
Low PCO2 level reflect to respiratory compensation for the metabolic acidosis
Sodium and potassium levels may be low, normal or high depending on the
amount of water loss
Elevated levels of creatinine, blood urea nitrogen (BUN), hemoglobin and
hematocrit

Prevention

patients must be taught “sick day” rules

GUIDELINE TO FOLLOW DURING PERIODS OF ILLNESS (“sick day rules”)

• take insulin or oral antidiabetes agents as usual
• test blood report glucose and test urine ketones every 3-4 hours
• report elevated glucose levels or urine ketones to the physician
• insulin-requiring patients may need supplemental doses of regular insulin q3-4
hrs
• if usual meal plan cannot be fallowed, substitute soft foods(eg. 1/3 cup regular
cola or orange juice, ½ cup broth, 1 cup Gatorade)q ½ - 1 hr to prevent
dehydration and to provide calories
• report nausea, vomiting and diarrhea to the physician, because extreme fluid loss
 may be dangerous.

• For patients with type 1 diabetes, inability to retain oral fluids, may warrant
hospitalization to avoid diabetic ketoacidosis and possibly coma.

Medical Management

1. Rehydration

important for maintaining tissue perfusion

fluid replacement
o Patients may need 6-10 liters of IVF initially
o After the first few hours: 0.45% NS 200-500ml/hr
o monitor V/S, I&O, electrolyte

2. Restoring Electrolytes

Potassium is a major electrolyte concern during treatment.

Factors related to treating DKA that reduce the serum potassium
concentration include:
o Rehydration, which leads to increased plasma volume and subsequent
decreased in the concentration of serum potassium. Rehydration also leads to
increased urinary excreation of potassium.
o Insulin administration, which enhances the movement of potassium from
the extracellular fluid into cells.

3. Reserving Acidosis

ketones bodies accumulate as result of fat breakdown,

hourly blood glucose values must be measured
administered IV solution with concentration
3. Hyperglycemic Hyperosmolar Nonketotic Syndrome

Serious condition in which hyperosmolarity and hyperglycemia predominate,

with alteration of the sensorium.

Clinical Manifestation

♦ hypotension
♦ dehydration ( dry mucous membrane, poor skin turgor)
♦ tachycardia
♦ variable neurologic signs (eg. Alteration of sensorium, seizures, hemiparesis)

Assessment and Diagnostic Findings

♦ laboratory Test
♦ blood glucose
♦ electrolytes
♦ BUN
♦ Complete blood count
♦ Serum osmolality
♦ And arterial blood gas analysis
♦ mental status changes,

Medical Management

♦ fluid replacement
♦ correction of electrolyte imbalance
♦ insulin administration

Nursing Management

♦ monitor vital sign, fluid status, and laboratory values

♦ maintain safety
♦ prevent injury
♦ I&O monitor

Nursing Intervention

1. Maintaining Fluid and Electrolyte Balance

a. Measured I&O
b. Administered IV fluids and electrolyte as prescribed
c. Encourage oral fluid intake
d. Monitor laboratory values of serum electrolytes(sodium &
potassium)
e. Monitor VS
f. For sign of dehydration
 2. Improving Nutritional Intake
a. Diet is planned with control of glucose as the primary goal.
b. Appropriate caloric intake allows the patient to achieve and
maintain the desired body weight
c. Encourage the patient to eat full meals and snacks as prescribed
3. Reducing Anxiety

a. Provide emotional support

b. Assisted to focus on learning self-care behaviors
c. Encourage to perform the skills that are feared most.
d. Positive reinforcement

4. Improving Self-Care
a. Patients teaching

5. Monitoring and Managing Potential Complication

a. Fluid Overload

Occur because of the administration of a large volume of fluid at a rapid rate

is often required to treat the patient with DKA or HHNS.
Risk is increased in elderly patients and in those with preexsisting cardiac
disease.
Nurse monitor fluid intake and keeps careful records of IV and other fluid
intake, with urine output measurement.

b. Hypokalemia

Low serum levels may result rehydration,

Prevention include cautions replacement of potassium

c. Hyperglycemia and Ketoacidosis

d. Hypoglycemia
e. Cerebral Edema
6. Monitoring Home and Community-based Care

a. Teaching Patients self-care

b. Continuing care

Long term complications

>Are seen in both type 1 and type 2 diabetes but usually do not occur with
in 1st 5-10 yrs. Of diagnosis
 >Renal disease is more prevalent among patient with type 1 diabetes
>Cardiovascular complication is more prevalent among older patient with
type 2 diabetes

MACROVASCULAR COMPLICATION

 Result from changes in the medium to large blood vessels

 Blood vessel wall thicken, sclerose and become occluded by plaque
that adheres to the vessel wall
 Three main types of macrovascular complication
a. CAD typical ischemic symptoms
b. CVA
c. Peripheral vascular disease.

>Cerebral blood vessels are similarly affected by accelerated

atherosclerosis, occlusive changes or the formation of an embolus.
> vascular that lodges in a cerebral blood vessel can lead to transient
ischemic attacks and stroke
> Cerebrovascular disease is common among diabetic patient. Recovery
from a stroke may be impaired in patient who have elevated blood glucose
level at the time of or immediately after stroke
> It is important to assess the blood glucose level
> atherosclerosis changes increasing of occlusive peripheral arterial
disease in patient with diabetes
> Severe form of arterial occlusive disease due to lower ext. is largely
responsible for the increased incidence of gangrene and subsequent
amputation in diabetic patient.
> Neuropathy and impairment in wound healing also play a role in diabetic
> signs and symptoms of peripheral vascular dse.
a. diminished peripheral pulse
b. intermittent claudication – pain in the buttocks, thigh, calf during
walking

ROLE OF DIABETES IN MACROVASCULAR DISEASE

 one of the main feature of diabetes in elevated blood glucose
 Risk factor for macrovascular disease
a. obesity
b. inc. triglyceride level
c. hypertension
 Diabetes itself is seen as an independent risk factor for the
development of accelerated atherosclerosis
 Other potential factor that may play a role in diabetes related
atherosclerosis include
a. platelet
b. clotting factor abnormalities
c. dec. flexibility of RBC
 d. changes in the arterial wall related to hyperglycemia
e. hyperinsulinemia

MANAGEMENT
 Diet and exercise- for managing obesity, hypertension, hyperlipidemia
 Use of medication- to control hypertension and hyperlipidemia
 Smoking cessation
 Control blood glucose- to reduce triglyceride\
 Patient may require increase ed the amount of insulin
 May need to switch from oral antidiabetic agents to insulin

MICROVASCULAR COMPLICATIONS AND DIABETIC RETINOPATHY

1. Diabetic microvascular dse.

a. AKA microangiopathy
b. Characterized by capillary basement membrane thickening
c. Basement membrane surrounds the endothelial cells of the
capillary
d. Increase blood glucose level reacts through a series of
biochemical response to thicken the basement membrane to
several times it’s normal thickness
e. 2 areas are affected
Retina
Kidney
f. changes in microvasculature
o microaneurysm
o intraretinal hemorrhage
o hard exudates
o focal capillary closure
2. Diabetic retinopathy- leading cause of blindness
a. is caused by changes in small blood vessel in the retina the
area of the eye that receive images and sends information to
the brain
b. richly supplied with blood vessels of all kinds
o small arteries
o veins
o arterioles
o venules capillaries
c. 3 main stages of retinopathy
o Non proliferative
o Preproliferative
o Proliferative
 type 1 and type 2 diabetes- lead to visual distortion and loss of central
vision
 preproliferative retinopathy- is considered a precursor to the more
serious proliferative retinopathy
 proliferative retinopathy widespread vascular changes and loss of
nerve fibers
 if visual changes occur during preproliferative stage caused by macular
edema
 PROLIFERATIVE RETINOPATHY
1. characterized by proliferation of new blood vessel
growing from the retina into the vitreous
2. Blood vessel are prone to bleeding
3. Vitreous hemorrhage caused visual losses associated
with proliferative retinopathy.
4. NORMAL vitreous are clear allowing light to be
transmitted to the retina
5. If hemorrhage occur the vitreous becomes clouded and
cannot transmit light resulting in loss of vision
6. Another consequence is that vitreous hemorrhage
resorption of blood in the vitreous leads to the formation
of fibrous scar tissue
7. scar tissue place traction in the retina resulating in retinal
detachment and subsequent visual loss
8. SIGNS AND SYMPTOMS
i. Blurry vision secondary to macular edema
ii. Indicative of hemorrhaging
1. floaters
2. cobwebs in visual field
3. sudden visual changes – spotty hazy vision
complete loss of vision
 DIAGNOSTIC PROCEDURE
1. Flourescein angiography – where dye is injected into an
arm vein is carried to various parts of the body
SIDE EFFECTS of this procedure
 Nausea during dye injection
 Yellowish fluorescent discoloration of the skin
and urine
 This side effects last for 12- 24 hours
 Allergic reaction Hives and itching
2. Opthalmoscope

 MEDICAL MANAGEMENT
1. intensive insulin therapy- decreases development of retinopathy
2. Argon laser Photocoagulation- main treatment of diabetic
retinopathy.
a. This is a laser treatment that destroys blood vessel and
areas of neovascularization
3. panretinal photocoagulation- patient increase risk for hemorrhaging
 -reduces the rate of progression to blindness
-this stops the widespread of new vessel and
hemorrhaging of damaged blood vessel
4. Vitrectomy- removal of fluid with a special drill like instrument and
replaced with saline
 NURSING MANAGEMENT
- regular opthalmoligoc examination
- Blood glucose control
- Self management of eye care regimen

NEPHROPATHY
- Patient with type 1 diabetes frequently show initial
signs of renal disease after 10-15 yrs
- Type 2 diabetesw develop renal disease within 10
yrs of the diagnosis
- Soon after the onset of diabetes and especially if the
glucose levels are elevated, the kidney’s filtration
mechanism is stressed, allowing blood protein to
leak into the urine. Pressure in the blood vessels of
the kidney increases
ASSESSMENT
Albumin is the most important blood proteins that leaks into the
urine
1. urine should be checked annually for microalbuminuria
2. Urine dipstick test for albumin, creatinine and BUN level are
obtained
MANAGEMENT
- Control of hypertension – use of ACE inhibitors
- Prevention or treatment of UTI
- Avoidance of nephroroxic substances
- Adjustment of medication as renal Ffunction
changes
- Low Sodium diet
- Low protein diet
>if the patient has already developed microalbuminuria and level exceeds
30mg/24hours in 2 consecutive test. An ACE inhibitor should be
prescribed
 IN chronic endstage of renal failure
1. Hemodialysis
2. Peritoneal dialysis has major risk factor --- infection and
peritonitis
 Laser or surgery may be performed

DIABETIC NEUROPATHIES
- Include the peripheral sensorimotor, autonomic and
spinal nerve
 - Elevated blood glucose level over a period of years
have been implicated in the etiology of neuropathy
- Capillary basement membrane thickening and
demyelinization of the nerves related to
hyperglycemia
- Nerve conduction is disrupted when there are
aberration of the myelin sheaths
- Most common type of diabetic neuropathy are
1. sensorimotos polyneuropathy commonly
affects the distal portions of the nerves
2. Autonomic neuropathy
3. Cranial nerve also occurs in diabetes common
among elderly
Peripheral Neuropathy
Signs and symptoms
1. paresthesia
2. burning sensation
3. feet become numb
4. decreased sensation of light touch which can lead
to an unsteady gait
5. decreased sensation to pain and temperature
place patient with neuropathy at high risk for foot
injury
6. Chariot joint – neuropathy related to joint.
Abnormal distribution on joint due to lack of
propioception
7. On physical examination the there is a decreased
in deep tendon reflex
MANAGEMENT
- intensive insulin therapy and control of blood
glucose level that delays the progression of
neuropathy
- for some patients neuropathic pain spontaneously
resolve within 6 mos.
- Nonopiod analgesic
- Triclylic antidepressant
- Transcutaneous electric nerve stimulation
AUTONOMIC NEUROPATHY
- THERE ARE THREE MANIFESTATIONS
1. cardia
2. GI
3. renal system
- Cardiovascular symptoms range from fixed, slightly
tachycardic heart rate, orthostatic hypertension,
silent or painless myocardial ischemia and infarction
 - Delayed gastric emptying bloating, nausea and
vomiting
- In addition there is unexplained absorption of
glucose from ingested food secondary to the
inconsistent gastric emptying
- Urinary retention a decreased sensation of bladder,
fullness and other urinary symptoms of neurologic
bladder result form autonomic neuropathy
- HYPOGLYCEMIC UNAWARENESS
1. autonomic neuropathy of the adrenal medulla
is responsible for diminished or absent
adrenergic symptoms of hypoglycemia.
a. Patient may report that they no longer
feel the shakiness, sweating,
nervousness and palpitations
associated to hypoglycemia
2. Sudomotor neuropathy
- refers to a decrease or absence of sweating
(adhidrosis) of the extremities
3. Sexual dysfunction
- impotence in men and
- decreased libido, reduced vaginal secretions
in women
- if there is vaginal infection there is vaginal
itching, decreased lubrication and tenderness

-
MANAGEMENT
-
Avoid strenuous activities
-
High sodium diet in orthostatic hypotension
-
The discontinuation of medication that impede
autonomic response and use of sympathomometics
and other agents
- That stimulate an autonomic response and the use
of lower body elastic garments that minimize
venous return and prevent pooling of blob in the
extremities
- Treatment delayed gastric emptying includes low fat
diet, small frequent meals, close blood glucose
control and the use of other agents that increases
gastric motility
- Treatment of diarrhea bulk forming laxative or
antidiarrheal agents
- Treatment for constipation use laxative and enemas
FOOT AND LEG PROBLEMS
- Complications of diabetes that contribute to the
increased risk of foot infection…
 1. Neuropath: sensory neuropathy leads to loss of
pain and pressure sensation and autonomic
neuropathy leads to dryness and fissuring of
the skin(secondary to sweating decrease
2. Peripheral vascular dse. Poor circulation of the
lower ext,. contributing to poor wound healing
and development of gangrene
3. immunocompromise hyperglycemia impairs the
ability of specialized leukocytes to destroy
bacteria.
- typical sequence of events in the development of
diabertic foot ulcer begins with a soft tissue injury of
the foot. Formation of a fissure between the toes or
in an area pf dry skin or formation of callus.
- Drainage, swelling redness from cellulitis of the leg
or gangrene may be the 1st sign of foot problems
- Treatment of foot ulcer involves bedrest, antibiotics
and debridement
- In patient with peripheral vascular dse. Ulcers of the
foot may not heal because there is decrease oxygen
- Amputation may be necessary to prevent infection
HIGH RISK PERSONS ARE
1. Duration of diabetes more than 10n years
2. age older than 40 yrs.
3. history of smoking
4. decreased peripheral pulse
5. decreased sensation
6. anatomic deformities
7. history of foot ulcer or amputation

MANAGEMENT
1. the feet must be inspected daily for redness, blisters, fissures,
calluses, ulceration, changes in skin temperature and
development of deformities
Aspect of preventive foot care
- proper bathing, drying, and lubricating the feet
- wearing closed toe shoe that fit well
- trimming of toenails
- reducing risk factors such as smoking, elevated
lipids
- avoiding home remedies to treat foot problems
HYPERGLYCEMIA DURING HOSPITALIZATION
Factors that may contribute to hyperglycemia
1. changes in the usual treatment regimen
2. medications
3. IV dextrose
 4. mismatched timing of meals and insulin
- short acting insulin is usually needed to avoid
postprandial hyperglycemia
- IV antibiotics should be mixed in normal saline to
avoid excess infusion of dextrose
HYPOGLYCEMIA DURING HOSPITALIZATION
- Factors that may contribute to hypoglycemia
1. Overuse of regular insulin
2. lack of dosage change when dietary intake is
changed
3. overuse medications for hyperglycemia
- successive does of subcutaneous regular insulin
should be administered no more frequently that
every 3-4 hours
- Should have snacks\

Common alteration in Diets

1. NPO- if the patient has procedure usual insulin

dosage should be changed
2. Clear fluid Diet- patient may take juice and
gelatin desserts
3. Enteral tube feeding
4. Parenteral nutrition
5. hygiene- foot should be clean and dried, use
lubricating lotion to