DIABETES MELLITUS

DEFINITION:

- Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose).
- 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 and urine.

ANATOMY AND PHYSIOLOGY:

Islet of Langerhans

1. Insulin is secreted by beta cells in the pancreas

and it is an anabolic hormone.
2. When we consume food, insulin moves glucose
from blood to muscle, liver, and fat cells as
insulin level increases.
3. The functions of insulin include the transport
and metabolism of glucose for energy,
stimulation of storage of glucose in the liver
and muscle, serves as the signal of the liver to
stop releasing glucose, enhancement of the
storage of dietary fat in adipose tissue, and
acceleration of the transport of amino acid into
cells.
4. Insulin and glucagon maintain a constant level
of glucose in the blood by stimulating the
release of glucose from the liver.

ETIOLOGY:

TYPE 1

- The exact cause of type 1 diabetes is unknown. What is known is that your
immune system — which normally fights harmful bacteria or viruses —
 attacks and destroys your insulin-producing cells in the pancreas. This
leaves you with little or no insulin. Instead of being transported into your
cells, sugar builds up in your bloodstream.
- Genetics. Genetics may have played a role in the destruction of the beta cells in type 1 DM.
 Scientists have figured out that type 1 diabetes can develop in people who have a particular HLA
complex. HLA stands for human leukocyte antigen, and antigens function is to trigger an
immune response in the body.
 There are several HLA complexes that are associated with type 1 diabetes, and all of them are
on chromosome 6.

TYPE 2

- In prediabetes — which can lead to type 2 diabetes — and in type 2 diabetes, your cells become
resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this
resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in your
bloodstream.
- Weight. Excessive weight or obesity is one of the factors that contribute to type 2 DM because it causes
insulin resistance.
- Inactivity. Lack of exercise and a sedentary lifestyle can also cause insulin resistance and impaired
insulin secretion.

SYMPTOMATOLOGY:

- Frequent urination (Polyuria) = If the blood sugar level crosses its normal limit the body will try to
remove the excess of circulating blood glucose through kidney. While doing so, the kidneys will filter
out more water from the circulating blood. Thus, you will pass large quantity of urine. At the same time
the kidney will not be able to absorb all the sugar and some amount of sugar will be lost in urine.
- Increased thirst (Polydipsia) = The main reason underlying this symptom is high level of sugar in blood.
The kidney tries to flush out sugar by increasing the amount of urine excretion. Since more water is lost
through urine the body cells become dehydrated which automatically increases the thirst response.
After drinking plenty of water it is again excreted as urine as the body tries to remove excess of sugar
via urine. Hence the body cells are not replenished with the lost fluid and the thirst centre is triggered
frequently to quench the thirst. Diabetic patient thus remains thirty even after drinking large amount of
water.
- Extreme hunger (Polyphagia) = The food consumed by normal people is usually converted into glucose
that acts as energy source for the body cells. The pancreas produce insulin hormone in body that
supports the passage of glucose to the body cells. But, in diabetic patients the pancreas never functions
optimally and can't produce sufficient insulin hormone to facilitate the passage of glucose to the cells
and hence it keeps the body cells starving for glucose. The brain cells become aware about the cellular
responses and trigger the center in hypothalamus to increase hunger and appetite. So, diabetic patients
often remain hungry even after consuming full meals.
- Unexplained weight loss
- Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that
happens when there's not enough available insulin)
- Slow-healing sores
GENERAL PATHOPHYSIOLOGY:

MEDICAL MANAGEMENT

LABORATORY TEST:

(1) “GLYCATED HEMOGLOBIN (A1C) TEST”

- This blood test indicates your average blood sugar level for the past two to three months. It measures
the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells.
The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level
of 6.5 percent or higher on two separate tests indicates that you have diabetes. An A1C between 5.7
and 6.4 percent indicates prediabetes. Below 5.7 is considered normal.
(2) “RANDOM BLOOD SUGAR TEST”
- A blood sample will be taken at a random time. Regardless of when you last ate, a random blood sugar
level of 200 milligrams per deciliter (mg/dL) — 11.1 millimoles per liter (mmol/L) — or higher suggests
diabetes.
(3) “FASTING BLOOD SUGAR TEST”
- A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL
(5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is
considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have
diabetes.
(4) “ORAL GLUCOSE TOLERANCE TEST”
- For this test, you fast overnight, and the fasting blood sugar level is measured. Then you drink a sugary
liquid, and blood sugar levels are tested periodically for the next two hours. A blood sugar level less
than 140 mg/dL (7.8 mmol/L) is normal. A reading of more than 200 mg/dL (11.1 mmol/L) after two
hours indicates diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L)
indicates prediabetes.
MEDICATIONS & TREATMENT AND/OR SURGERY:

TYPE 1

(1) “INSULIN INJECTABLES”

- Are Often First Step in the treatment of Ulcerative Colitis.

Injectable insulin comes in five types:

- Rapid-acting (taking effect within a few minutes and lasting 2-4 hours)
- Regular or short-acting (taking effect within 30 minutes and lasting 3-6 hours)
- Intermediate-acting (taking effect in 1-2 hours and lasting up to 18 hours)
- Long-acting (taking effect in 1-2 hours and lasting beyond 24 hours)
- Ultra-long-acting (taking effect in 1-2 hours and lasting 42 hours)

TYPE 2

(1) “METFORMIN”
- Generally, metformin is the first medication prescribed for type 2 diabetes. It works by improving the
sensitivity of your body tissues to insulin so that your body uses insulin more effectively.
- Metformin also lowers glucose production in the liver. Metformin may not lower blood sugar enough on
its own. Your doctor will also recommend lifestyle changes, such as losing weight and becoming more
active.
(2) “HEALTHY EATING”
 Fruits
 Vegetables
 Whole grains
- You'll also need to eat fewer animal products, refined carbohydrates and sweets.
- Low glycemic index foods also may be helpful. The glycemic index is a measure of how quickly a food
causes a rise in your blood sugar. Foods with a high glycemic index raise your blood sugar quickly. Low
glycemic index foods may help you achieve a more stable blood sugar. Foods with a low glycemic index
typically are foods that are higher in fiber.
- A registered dietitian can help you put together a meal plan that fits your health goals, food preferences
and lifestyle. He or she can also teach you how to monitor your carbohydrate intake and let you know
about how many carbohydrates you need to eat with your meals and snacks to keep your blood sugar
levels more stable.
(3) “PHYSICAL ACTIVITY”
- Everyone needs regular aerobic exercise, and people who have type 2 diabetes are no exception. Get
your doctor's OK before you start an exercise program. Then choose activities you enjoy, such as
walking, swimming and biking. What's most important is making physical activity part of your daily
routine.
- Aim for at least 30 minutes of aerobic exercise five days of the week. Stretching and strength training
exercises are important, too. If you haven't been active for a while, start slowly and build up gradually.
- A combination of exercises — aerobic exercises, such as walking or dancing on most days, combined
with resistance training, such as weightlifting or yoga twice a week — often helps control blood sugar
more effectively than either type of exercise alone.
- Remember that physical activity lowers blood sugar. Check your blood sugar level before any activity.
You might need to eat a snack before exercising to help prevent low blood sugar if you take diabetes
medications that lower your blood sugar.
 (4) “MONITORING BLOOD SUGAR”
- Depending on your treatment plan, you may need to check and record your blood sugar level every
now and then or, if you're on insulin, multiple times a day. Ask your doctor how often he or she wants
you to check your blood sugar. Careful monitoring is the only way to make sure that your blood sugar
level remains within your target range.
- Sometimes, blood sugar levels can be unpredictable. With help from your diabetes treatment team,
you'll learn how your blood sugar level changes in response to food, exercise, alcohol, illness and
medication.

NURSING MANAGEMENT:

1) Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals
and assist with compliance.
2) Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately
administer insulin.
3) Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve
mastery of technique by taking step by step approach.
4) Review dosage and time of injections in relation to meals, activity, and bedtime based on patients
individualized insulin regimen.
5) Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid
hypoglycemia.
6) Explain the importance of exercise in maintaining or reducing weight.
7) Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack
before exercising to avoid hypoglycemia.
8) Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair
distribution, pulses and deep tendon reflexes.
9) Maintain skin integrity by protecting feet from breakdown.
10) Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and
enhance peripheral flow.

POSSIBLE PRIORITY NURSING DIAGNOSIS:

(1) Risk for Unstable Blood Glucose r/t medication management.

(2) Imbalanced Nutrition Less Than Body Requirements r/t reduction of carbohydrate metabolism due
to insulin deficiency, inadequate intake due to nausea and vomiting.
(3) Fluid Volume Deficit r/t osmotic diuresis from hyperglycemia, polyuria, decreased fluid intake.
(4) Impaired Skin Integrity r/t decreased sensory sensation, impaired circulation, decreased activity /
mobilization, lack of knowledge of skin care.
(5) Activity Intolerance r/t weakness due to decreased energy production.

PROGNOSIS:

 Mean life expectancy amounts to about 70%, compared with the whole population. Mean survival after
manifestation is more than 18 years. Diabetic coma has almost disappeared as cause of death. Today,
approximately 75% of diabetics die from vascular complications, mainly from coronary heart disease.