Type 1 diabetes is a chronic disease that occurs when pancrease could not

produce enough insulin to control blood glucose. It is charaterized as an

autoimmune destruction of the beta-cells of the pancrease islets that produce
and release insulin. It is also characterized by the There is currently no cure
for this type of diabetes. Individuals with Type 1 diabetes usually require
exogenous insulin (source from outside the body) treatment to control the
blood glucose levels. The three basic symptoms of diabetese mellitus are
polyuria, polydispia, and polyphagia.
Type 1 diabetes mellitus affects the metabolism of fat, protein, and
carbohydrate. Glucose then accumlates in the blood and appears in the urine
as the renal threshold for glucose is exceeded, producing an osmotic diuresis
and symptoms of pulyuria and polydispy. Protein and fat breakdown will occur
due to lack of insulin, thus resulting in weight loss as the breaks down the
stored fat, it creats a condition that makes individual feel hungry and wants
to eat more and more (McCance, Huether, Brashers, Rote). This condition is
known as polyphagia, thus individuals who are type 1 diabetes may look very
thin.
Diabetic or hyperglycdemic with Ketoacidosis is caused by an absence or
markedly inadequate amount of insulin. The deficit in insulin results in
disorders in the methabolism of carbohydrate, protein, and fat, which results
in hyperglycemia, dehydration and electrolyte loss, and acidosis (diabetic
acidosis). One of the signs of ketoacidosis is a fruity ordor. To further assess
for ketoacidosis, a laboratory test can be performed and the expected
findings should correspond to the following results:

The serum blood glucose level should be greater than 250 mg/dL

The plasma pH level should be less than 7.3

The plasma bicarbonate level should be less than 15 mEq/L

Eleveted serum creatinine and BUN levels

Serum osmolarity is between 300 and 350 mOsm/L

Serum amylase and lipase is elevated

The serum ketone should be present in both blood and urine

Serum potassium and chloride levels should be elevated

Serum sudium (hyponatremia), phosphate and magnesium

(hypomagnesemia) levels should be decreased

Diabetic Ketoacidosis, when hospitalized the nurse monitor the blood and
urine tests closely. If not hospitalized the individual should contact his/her
healthcare provider immediately or go to a nearby emmergency room. The
reason is that diabetic ketoacidosis has a high mortality rate which results
from not having enough insulin. Not enough insulin means that the body will
not be able to use glucose for energy and has to look for where to get it.
Normally, the alternative is the stored fat as explained above and as fat is
broken down it creates toxic waste, an acid-by-products known as ketones ,
which can poison the body. When ketones accumulated so much in the blood
they can cause potentially life-threatening and chemical imbalance known as
ketoacidosis. It is a seriuos condition and the most serious complication of it
is cerebral edema especially in children.
The primary course of treatment for this 48 year old woman will include fluid
resuscitation, insulin infusion, electrolytes and phosphate adjustment
intravenously. These therapies will reverse dehydration, restore normal blood
glucose level and electrolytes imbalance, and lower blood acid level.
Potassium is added to the IV infusion to correct the depletion of this
important body electrolyte. On the other hand, the therapies must be
monitored carefully. An excessive amount of hydration could lead to brain
swelling (cerebral edema). Insulin must be given promptly, as a continous
infusion and not as a bolus to stop further ketone formation and to stabilize
tissue function by driving available potassium back into the tissue cells. Once
blood glucose has fallen to a particular level, normally 300 mg/dL, insulin
need to be coadministered with glucose to prevent the incident of
hypoglycemia
(http://www.emedicinehealth.com/diabetic_ketoacidosis/page6_em.htm).
Regular and analog human insulins are used for correction of hyperglycemia,
unless bovine or pork insulin is the only available insulin. Clinical
considerations in treating diabetic ketoacidosis (DKA) include the following:
(1) only short-acting insulin is used for correction of hyperglycemia in DKA,
(2) the optimal rate of glucose decline is 100 mg/dL/h, (3) the blood glucose
level should not be allowed to fall lower than 200 mg/dL during the first 4-5
hours of treatment, and (4) avoid induction of hypoglycemia because it may
develop rapidly during correction of ketoacidosis and may not provide
sufficient warning time. (http://emedicine.medscape.com/article/118361treatment).
As I mentioned above hospitalized patients with diabetic ketoacidosis are
mornitored with appropriate blood and urine tests. While mornitoring the
patient's' IV fluid adminsitration, administration of insulin to lower blood
glucose and serum acetone, the electrolytes to correct imbalance, and the
assessment of renal and cardipulmonary status related to hydration and
electrolyte leve, level of consciousness, it is important to keep an eye on the

signs of potassium imbalance that may result from hyperinsulinemia and

osmotic diuresis. The reason why potasium should be mornitored is because
threating hyperglycemia with insulin results in rapid depletion of potassium
as potassium moves back into the cells once insulin becomes available. The
movement of potassium out of extracellular fluid into the cell affects cardiac
functioning. For this reason, cardiac mornitoring is very important aid in
detecting hyperkalemia and hypokalemia characteristic changes, which can
be observable on electrocardiogram. The imbalance in serum potassium level
could lead to Myocardial infarction as a precipitating cause of diabetic
ketoacidosis in older clients or cerebral edema in children as mentioned
above. (http://www.aafp.org/afp/2005/0501/p1705.html) & Med-Surg
textbook).
During the first 24 hours of continous insulin infusion, there is a risk for
hypoglycemia. This condition in simple term is a low blood sugar. As insulin is
given during the course of treatment for diabetic ketoacidosis, glucose is
rapidly picked up by the cells causing the serum blood glucose level to drop.
It may significantly drop to a lower level to result in hypoglycemia. In view of
this hypoglycemia is one of the major complications of diabetic ketoacidosis
to monitor during first 24 hours of treatment. Cerebral edema is the most
fearful complication that can result in the first 24 hours of treatment as well.
This normally occurs as a result of excessive hydration in order to restor fluid
imbalnace. As earlier mentioned, hyperkalemia and hypokalemeia is another
serious complication that could occur as a result of insulin therapy.
Until recently the only way to test for ketones was to use a urine test strip.
This has some disadvantages:
1. Urine Ketone Testing is not specific because it can be interfered by many
things.
2. There are three types of ketones - called acetone, acetoacetate and hydroxybutyrate. The most common ketone when you are developing
ketoacidosis is -hydroxybutyrate. Unfortunately urine tests don't detect hydroxybutyrate.
3. Ketones accumulate in urine over several hours, so measuring them in
urine cannot tell you what the levels are right now.
4. When you have - or are developing - ketoacidosis you can become very
dehydrated so a urine sample can be difficult to obtain.
It is recommended you test your blood -Ketone because Ketones are
detectable in the blood far earlier than in urine, so blood -Ketone testing can
give early warning of impending DKA.
(http://www.abbottdiabetescare.ca/adc_ca/url/content/en_CA/40.20.40:40/gen

eral_content/General_Content_0000315.htm).
Also, as stated by Lippincot, WIlliams and Wilkins, despite their convenience,
urine tests don't always reflect blood glucose levels accurately.
The management of diabetes self-care is largely the responsibility of the
patient, with more emphasis on prevention of complications as discussed in
paragraphy... Adherence to diabetes self-care regimens can be difficult and
that requires the patient to make many dietary and lifestyle changes. In
addition to monitoring the blood glucose and ketone levels, adhering to
lifestyle changes such exercise and nutrition, the nurse should emphasize
most the foot care, which tends to be forgotten, but obviously carries high
consequences when neglected. Foot care comes into play because diabetes
affects all types of nerves, including peripheral, autonomic, and spinal
nerves. The decrease in sensation of pain and temperature places the
individual at high risk for injuries and infections especially in the lower
extremeties. In view of this fact, the nurse should instruct Ms. X to inspect her
feet on a daily basis by looking at the bare feet, using a mirror to check the
bottoms of the feet, monitor for changes in temperature, blisters, cuts, red
spots, and swelling. Ms X should be taught how to wash her feet every day
using warm water (do not soak them), and then dry feet very well after
washing. The toe nails should be trimed every week, and the shoes and socks
should just fit, and not too tight to allow for blood to flow freely (Lippincot,
WIlliams, and Wilkins). In case of diabetic neuropathy and the client happens
to sustain foot injury, the healing of the wound is impaired. Because most
individuals that have foot amputation are diabetic patients, foot care is very
important and must be discussed with each diabetic client before discharged.

Individuals diagnosed with Type 1 diabetes use exogenous insulin for lier
because the body has lost its ability to produce insulin. In many cases, insulin
should be administered two or more times a day. However, the administration
of insulin depends on the level of glucose in the blood, thus accurate level of
blood glucose is esseential.
As explained above insulin is used for treating and sustaining life of diabetic
individuals especially in type 1 diabetes where the pancrease is not
producing enough insulin or not at all. There use to be animals (beef and
pork) derived insulin in the past, but today insulin is derived from human
through genetic engineering. Exogenous Insulin is grouped in categroies of
onset, peak and duration of action. There are rapid-acting, short-acting,
intermediate-acting, long-acting, and combination (premixed) insulin. Insulin
is not just prescribed for individuals. It's properties are matched with the
individual's diet and activities before prescribing. Insulin can also mix

together in order to tailor treatment to client's lifestyle, eating and activity

patterns. Which ever insulin treatment is chosen, all insulin preparations start
with the regular insulin as the base. To achive different onsets, peak and
duration, Zinc, protamine and acetate buffer are added and manipulated as
needed. For example zinc and protamine when added will produce an
intermediate-acting NPH (Neutral Protamine Hagedom) insulin.
Insulin can be given as one injection per day or upto four times a day.
Normally the body produces insulin during meal time for the conversion of
carbohydrate ingested to glycogen. If that's the case, the administration of
synthetic insulin, which mimics endogenous insulin should be targeted
towards mealtime for effective treatment.
Ms. X was prescribed 10 units of regular and 18 units of NPH insulin to be
taken before breakfast, and 5 units if regular and 12 units NPH at dinnertime.
Regular insulin is short-acting and NPH is an intermediate acting insulin.
Unlike the rapid acting, which has onset of 15 minutes, peak of 60 to 90
minutes for a duration of 3 to 4 hours, the short -acting insulin has an onset
of 30 to 60 minutes with 3 to 3 hours peak and lasts from 3 to 6 hours. The
intermediate-acting NPH has an onset of 2 to 4 hours with peak of 4 to 10
hours and could last from 10 to 16 hours. For a mixed-dose of short-acting
and intermedaite-acting, the onset could be as short as 30 minutes to 4 hours
with a peak ranging from 2 to 10 hours and lasting effect between 3 hours to
16 hours. Although hypoglycemia is not out of question, but the duration
effect of the mixed dose is long enough to protect individual in between
meals.
The discharged teaching learning about the mixed-dose of short and
intermediate acting insulin, should be stated as follows:
Insulin preparation
Handwashing is very important before handling the medication to control
infection at the injection site
Identify the insulin to be injected, and check the expiration date
Gently rotate the NPH insulin bottle and wipe the vails with alcohol sponge
Client should use 0.3 mL syringe, which is the normal size for injecting 30
units or less of insulin
For breakfast:

1. Draw back 28 units of air which is equal to total amount of both regular
and NPH insulin to be administered into the stringe

2. Inject 18 units of air into NPH vail and remove syringe

3. Inject 10 units of air into regular vail, and while the syringe is still in
the regular invert the vail and draw up 10 units of regular insulin, then
withdraw syringe

4. Insert syringe into NPH, without adding more air to NPH vail, carefully
withdraw 18 units of NPH
For dinner:

5. Draw back 17 units of air which is equal to total amount of both regular
and NPH insulin to be administered into the stringe

6. Inject 12 units of air into NPH vail and remove syringe

7. Inject 5 units of air into regular vail, and while the syringe is still in the
regular invert the vail and draw up 5 units of regular insulin, then
withdraw syringe

8. Insert syringe into NPH, without adding more air to NPH vail, carefully
withdraw 12 units of NPH
Instruct client that insulin is injected by keeping the syringe at 45 degree
angle, and then Inject insulin into the prefer site (abdomen)
Advise client to rotate injection site (still abdomen) to prevent irritation of
skin
Caution patient not inject insulin to the site that will be exercised, for
example the client should not inject insulin into the thigh and then go
jogging. This is because exercise will increase the body heat and circulation,
which may increase rate of absoption and speeds up the onset of insulin.
Caution client to avoid storing insulin in extreme hot or freezing temperature,
which could alter the molecule.

Nursing management of diabetes mallitus

Ignorance is one of the major factors that affect management of diabetes
mellitus. As a result diabetes may not be diagnosed until one or two
complications are manifested. Hence, a little bit of learning about diabetes
and associated complications will help Ms X to manage the disease. As
already stated above diabetes mellitus are of two kinds, type 1 and type 2,
and both present with the same most common signs and symptomssuch as
polyuria, polydipsia, and polypgagia. Diabetes type 2 occurs most often at

older age as a result of the body becoming resistant to insulin and the
manifestation of hyperglycemia. The type 1 diabetes can occur at any age for
two reasons, bacterial infection that causes autoantibodies against the beta
cells of the pancrease and resultant destruction of 90% of the beta cells.
Normally clients with type 1 diabetes use exogenous insulin to sustain life.
One of the major complications of role of a nurse in managing type 1
diabetes mellitus is hyperglycemia , lipolysis (fat decomposition) and protein
catabolism, which leads to diabetic ketoacidosis. Ketoacidosis occurs as a
result of profound deficiency of insulin, and it's characterized by high blood
sugar, ketosis, acidosis and dehydartion.
As stated above individuals with type 1 diabetes depend on exogenous
insulin to sustain life. Insulin prescription is based on individual needs and
activity level. Individuals with diabetic ketoacidosis can slip into coma and
may die. In addition to other risk factors and for the fact that diabetes can
involve variety of physiological disorders (blindness, kidney disease,
neuropathy leading to amputation), most importantly it requires lifetime
management, and client must learn to balance multiple factors. Client must
learn daily self-care to minimize or prevent fluctuation of blood glucose and
it's complications.
It is the nurse's responsibilty to assess each client's readiness to learn and
determine teaching method that will impact proper knowledge. Having stated
this, will impact the following survival skills to Ms. X in order to be able to
manage her diabetes at home:

The basic definition of diabetes as explained above, and also, includes

knowledge about normal blood glucose levels , the effect of insulin and
how exercise could lower blood glucose level, effect of food (high
caloried food) and stress (illness, infections), and the basic treatment
approaches.

The treatment regimen for Ms X includes insulin administration and

possible other oral medications the doctor may prescribe. It is nurse's
responsibility to educate the client the need for continuous insulin
therapy as prescribed without missing a dose. Missing doses could
result in more episodes of hypoglycemia and subsequently
ketoacidosis. Also, Ms X should be educated on the meal planning such
as the nutritional values of the five food groups, and the timing of each
meal. The timing is very important because of the administration of
insulin (onset, peak and the duration) and it effect.

Ms X should be tought how to monitor blood glucose and ketones. Her

doctor ordered blood glucose monitoring instead of urine testing, the
nurse should enphasis on the importance of complying with this

change. As I explained above, urine testing though convinient, is not

very effective in detecting ketones. Blood test detects the beta ketones
before the manifestation of DKA. The should educate Ms X on how to
perform the blood test and where to obtain the testing kits. Ms X
should keep proper record of the test results.

The nurse should educate Ms X on the signs and symptoms of acute

complications of hypoglycemia and hyperglycemia to watch out for,
and what to do in case emergency. In case of hyperglycemic effect, Ms
X should take 15 g of fast-acting carbohydratesuch as 4 to 6 oz of fruit
juice or soda, 3 to 4 commercial glucose tablets, 6 to 10 hard candies,
or 2 to 3 teaspoons of sugar or honey. Ms X should carry any one of
these rescue glucose boost all the time.

Ms X should be instructed on where to buy and store insulin, the

syringes,and the monitoring kit. The nurse should also instruct her on
when to contact her healthcare provider in an emergency situation.

Lastly, while Ms X is complying with her insulin treatment, she should

be taught how to adjust (increase or decrease) her insulin based on her
blood glucose levels. Also the nurse should teach Ms X how to care for
her legs and feet, and eyes to prevent further complications or
manifestations of diabetes.

To prevent future emergency episodes, Ms X should comply with her

treatment regimen and take all necessary precuations outlined by the nurse
in her teaching. In addition to medications, Ms X should try to make
necessary lifestyle changes to include exercise and dietary that will help her
in managing and controlling her blood surgar and ketones
Ms X should carry all her glucose rescue medication or beverage of her
choice all the time. It is important that also carry medic-alert explaing her
condition as well.
Above all, Ms X should comply with blood glucose and ketone testing per
physician's order.

for effective treatment

Many patients with diabetes die from diabetic ketoacidosis (DKA) every year.
DKA is caused by reduced insulin levels, decreased glucose use, and
increased gluconeogenesis from elevated counter regulatory hormones,
including catecholamines, glucagon, and cortisol. DKA primarily affects
patients with type 1 diabetes, but also may occur in patients with type 2
diabetes, and is most often caused by omission of treatment, infection, or
alcohol abuse.1 Use of a standard protocol provides consistent results in
treating DKA.2 An evidence-based guideline for the management of DKA from
the American Diabetes Association (ADA) is the basis for much of this
article.3
The management of diabetes self-care is largely the responsibility of the
patient. With more emphasis on the prevention of complications, adherence
to diabetes self-care regimens can be difficult. Diabetes self-care requires the
patient to make many dietary and lifestyle changes. This study will explore
patient perceptions of diabetes self-care, with particular reference to the
burden of self-care and coping strategies among patients.
(http://www.biomedcentral.com/1472-6823/9/6)-Self-care coping strategies in
people with diabetes: a qualitative exploratory study - 2009 Collins et al;
licensee BioMed Central Ltd.

http://www.merck.com/mmpe/sec12/ch158/ch158c.html
http://type1diabetes.about.com/od/schooldaycareandlaws/a/keto_emergency.
htm
http://www.wrongdiagnosis.com/d/diabetic_ketoacidosis/book-diseases19a.htm

Type 1 diabetes is a chronic disease that occurs when pancrease could not
produce enough insulin to control blood glucose. It is charaterized as an
autoimmune destruction of the beta-cells of the pancrease islets that produce
and release insulin. There is currently no cure for this type of diabetes.
Individuals with Type 1 diabetes usually require exogenous insulin (source
from outside the body) treatment to control the blood glucose levels. The
three basic symptoms of diabetese mellitus are polyuria, polydispia, and
polyphagia.
Type 1 diabetes mellitus affects the metabolism of fat, protein, and
carbohydrate. Glucose then accumlates in the blood and appears in the urine
as the renal threshold for glucose is exceeded, producing an osmotic diuresis

and symptoms of pulyuria and polydispy. Protein and fat breakdown will occur
due to lack of insulin, thus resulting in weight loss as the breaks down the
stored fat, it creats a condition that makes individual feel hungry and wants
to eat more and more (McCance, Huether, Brashers, Rote). This condition is
known as polyphagia, thus individuals who are type 1 diabetes may look very
thin.
Diabetic or hyperglycdemic with Ketoacidosis is caused by an absence or
markedly inadequate amount of insulin. The deficit in insulin results in
disorders in the methabolism of carbohydrate, protein, and fat, which results
in hyperglycemia, dehydration and electrolyte loss, and acidosis (diabetic
acidosis). One of the signs of ketoacidosis is a fruity ordor. To further assess
for ketoacidosis, a laboratory test can be performed and the expected
findings should correspond to the following results:

The serum blood glucose level should be greater than 250 mg/dL

The plasma pH level should be less than 7.3

The plasma bicarbonate level should be less than 15 mEq/L

Eleveted serum creatinine and BUN levels

Serum osmolarity is between 300 and 350 mOsm/L

Serum amylase and lipase is elevated

The serum ketone should be present in both blood and urine

Serum potassium and chloride levels should be elevated

Serum sudium (hyponatremia), phosphate and magnesium

(hypomagnesemia) levels should be decreased

Diabetic Ketoacidosis, when hospitalized the nurse monitor the blood and
urine tests closely. If not hospitalized the individual should contact his/her
healthcare provider immediately or go to a nearby emmergency room. The
reason is that diabetic ketoacidosis has a high mortality rate which results
from not having enough insulin. Not enough insulin means that the body will
not be able to use glucose for energy and has to look for where to get it.
Normally, the alternative is the stored fat as explained above and as fat is
broken down it creates toxic waste known as ketone, which can poison the
body. It is a seriuos and possibly life threatening condition and the most
serious complication of it is cerebral edema especially in children.
The primary course of treatment for this 48 year old woman will include fluid

resuscitation, insulin infusion, electrolytes and phosphate adjustment

intravenously. These therapies will reverse dehydration, restore normal blood
glucose level and electrolytes imbalance, and lower blood acid level.
Potassium is added to the IV infusion to correct the depletion of this
important body electrolyte. On the other hand, the therapies must be
monitored carefully. An excessive amount of hydration could lead to brain
swelling (cerebral edema). Insulin must be given promptly, as a continous
infusion and not as a bolus to stop further ketone formation and to stabilize
tissue function by driving available potassium back into the tissue cells. Once
blood glucose has fallen to a particular level, normally 300 mg/dL, insulin
need to be coadministered with glucose to prevent the incident of
hypoglycemia
(http://www.emedicinehealth.com/diabetic_ketoacidosis/page6_em.htm).
Regular and analog human insulins are used for correction of hyperglycemia,
unless bovine or pork insulin is the only available insulin. Clinical
considerations in treating diabetic ketoacidosis (DKA) include the following:
(1) only short-acting insulin is used for correction of hyperglycemia in DKA,
(2) the optimal rate of glucose decline is 100 mg/dL/h, (3) the blood glucose
level should not be allowed to fall lower than 200 mg/dL during the first 4-5
hours of treatment, and (4) avoid induction of hypoglycemia because it may
develop rapidly during correction of ketoacidosis and may not provide
sufficient warning time. (http://emedicine.medscape.com/article/118361treatment).