Nursing Care of the Patient

with Diabetes Mellitus

Debbie Beyer RN MSN
Associate Professor
Miami UniversityHamilton
Campus
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Diabetes Mellitus
ReviewIslets of Langerhans
Alpha Cells
Produce glucagon

Beta Cells
Produce insulin

Facilitates the uptake and use of glucose

Prevents excessive breakdown of glycogen in liver and muscle
Insulin decreases blood glucose levels
Facilitates lipid formation
Inhibits the breakdown and mobilization of stored fat and helps
amino acids move into cells to promote protein synthesis

Delta Cells
Produce Somatostatin
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Diabetes Mellitus
Common Chronic Disease
Characterized by inappropriate
hyperglycemia caused by a deficiency of
insulin or by cellular resistance to the action
of insulin
Type 1
Pancreatic islet cell destruction
Total deficit of circulating insulin

Type 2
Insulin resistance with a defect in compensatory
insulin secretion
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Diabetes Mellitus
Type 1
Onset usually in childhood and adolescence
May occur at any age
Characterized
Hyperglycemia
Breakdown of body fats and proteins
Development of ketosis

Risk Factors
Genetics
Environmental factors
Viral infection or chemical toxin
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Diabetes Mellitus
Type 1
Manifestations

Hyperglycemia
Polyuria- excessive production of urine
Glucosuria- excess sugar in urine
Polydipsia- abnormally great thirst
Polyphagia-excessive hunger
Weight loss
Malaise
Fatigue

Treatment requires exogenous (external) source

of insulin
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Diabetes Mellitus
Type 2
May occur at any age but usually seen in middle age and older people
Most common form of DM
Characterized
Fasting hyperglycemia that occurs despite available insulin
Level of insulin available varies, the function is impaired by insulin resistance in
peripheral tissues
Nonketotic form of DMinsulin enough to prevent breakdown of fats but not adequate to
lower blood glucose levels
Resistance is increased by obesity, inactivity, illnesses, medications and increasing age.

Risk Factors

Heredity
Obesity
Physical inactivity
race/ethnicity
History of gestational diabetes for women or delivering a baby weighing more than 9 lbs.
Hypertension (>130/85) low HDL or high triglyceride level.
Metabolic Syndrome

Diabetes Mellitus
Type 2
Manifestations
Slow onset of manifestations and is often unaware
Hyperglycemia is usually not as severe as a
person with Type 1
Polyuria
Polydipsia
Polyphagia is not often seen and weight loss is not
common.
Manifestations of hyperglycemia: blurred vision,
fatigue, paresthesias, and skin infections.
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Diabetes Mellitus
Type 2
For the older adult
Normal physiological changes of aging may
mask DM
May not have the same classic symptoms of
polyuria and polydipsia
Any change in status in an older adult
should include evaluation of the onset of
Type 2 diabetes mellitus

Diabetes Mellitus
Interdisciplinary Care
Treatment focus is to maintain blood
glucose control at levels as near to
normal through medications, dietary
management and exercise.
Tight blood glucose control decreases
the risk of the development and
progression of complications involving
the eyes, the kidneys and the nervous
system.
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Diabetes Mellitus
Interdisciplinary Care
Diagnostic Screenings
Hyperglycemia
Fasting plasma glucose > 126 mg/dL
Fastingno caloric intake for 8 hours
Normal = 100 mg/dL;
prediabetes fasting 100-126;
DM >126
Two-hour plasma glucose > 200 mg/dL
During an oral glucose tolerance test
Normal <140 mg/dL; prediabetes 140-199; DM >
200
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Diabetes Mellitus
Interdisciplinary Care
Prediabetesterm used to describe
those at risk for developing DM

Increased levels of Hemoglobin A1C

Increased fasting blood glucose
Impaired plasma glucose
Treatment
Weight loss and increased physical activity
Monitor for development of DM

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Diabetes Mellitus
Interdisciplinary Care
Diagnostic Tests to Monitor DM Management
Fasting Blood Glucose
Normal 70-110 mg/dL

Oral glucose tolerance test

Glycosylated hemoglobin (hemoglobin A 1C)
Normal range 2-5%; 2.5-6% for a diabetic control and 6.1-7.5% for a
high average.
Poorly controlled greater than 7.5%

Urine Tests for glucose, ketones and albumin

Glucose = hyperglycemia
Not very accurate
Albumin=early onset of kidney damage
Ketones=to detect occurrence of diabetic ketoacidosis
**important for sick day management of Type I DM
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Diabetes Mellitus
Interdisciplinary Care
Urine Testing for Ketones and Glucose
One time was the only available method
Negative glucose in urine=less than 180 mg/dL however
the amount might rise in renal insufficiency and aging.
Used to monitor ketoacidosis in type 1 DM during illness

Monitoring Blood Glucose

Direct measurement of blood glucose
Self monitoringmany machinesuse specific materials
Continuous Glucose Monitoring (CGM) sensor to detect high
and low levelsmust be confirmed with actual fingerstick.

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Diabetes Mellitus
Interdisciplinary Care
Factors that affect glucose meter performance
Hematocrit
Higher hematocrit levelsglucose test falsely low
Lower hematocrit levelsglucose test falsely elevated
Anemia and sickle cell anemia

Other substances
Overdoses may cause inadequate results
Meters and supplies vary in sensitivity to medications

Using Correct Supplies and Sample Volume

Test strips must be compatible, not outdated or exposed to
air and humidity.
Insufficient amounts of blood can result in inaccurate results
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Diabetes Mellitus
Interdisciplinary Care
Medications
Type 1Must have insulin
Type 2Oral hypoglycemia medication; but
they may also require insulin if inadequate
control, or if they are subjected to a stressor
such as surgery.

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Diabetes Mellitus
Interdisciplinary Care
Insulin
Type 1require lifelong exogenous insulin
Insulin is not a cure for DMinsulin controls
hyperglycemia
May be required for other situations
Type 2 who cannot control with oral hypoglycemics
Those under physical stresssurgery, infection or those on
corticosteroids
Woman with gestational DM
People with diabetic ketoacidosis (DKA) or hyperosmolar
hyperglycemic state (HHS)
People who are receiving high-calorie tube feedings or
parenteral nutrition.
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Diabetes Mellitus
Interdisciplinary Care
Insulin
Sources
Animal (beef or pork no longer produced or marketed in U. S.
Now all synthesized

Insulin Preparations
Classified by Onset, Peak and Duration
Rapid acting
Short acting
Intermediate acting
Long acting
Combinations

Concentrations of Insulin
U 100 (100 units/mL)
Most common and standard concentration
U 500 (500 units/mL)
Used in rare cases and when patients require very large doses
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Diabetes Mellitus
Interdisciplinary Care
Insulin
Insulin Administration
Routes
Parenterallyall subcutaneous except regular insulin
can be given subcutaneously and by IV push route.
Continuous subcutaneous insulin infusion
Correctional doses of insulin
Basal, Prandial or Bolus, and/or Correction Therapies
Syringe and needle selection
Single use needles
Disposable insulin syringes
Multiple dose pens
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Diabetes Mellitus
Interdisciplinary Care
Insulin
Insulin Administration
Preparing the injection
Vial may be kept at room temp for 4 weeks
No air bubblescan alter amount of insulin
Pensstored at room temperature and discarded at
28 days
Sites of injection
Abdomen is recommended sitemost rapid
absorption
Subcutaneous sites
Observe for lipodystrophy and lipoatrophy
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Diabetes Mellitus
Interdisciplinary Care
Insulin
Insulin Administration
Mixing insulins
Commercially mixed insulins are
recommended
Avoid contaminating the regular insulin
Detemer (Levemir) and glargine (Lantus)
cannot be mixed with anything
Insulin regimens
Balance among insulin, diet and exercise
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Insulin used for Diabetes

Mellitus

(American Diabetes Association, 2013)

Also refer to your text, Chart 47-3 Page 1432

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Oral Hypoglycemic Agents used for

Type 2 Diabetes Mellitus
Sulfonylureas
Second Generation
Glipizide (Glucotrol, Glucotrol XL)
Glyburide (Diabeta)
Glimepiride (Amaryl)

Action: Stimulate the beta cells of the pancreas to

release more insulin and improves insulin sensitivity
Nursing Considerations

Usually taken 1-2 times per day before meals

Can cause hypoglycemia
Associated weight gain
Usually discontinued during acute hospitalization
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Oral Hypoglycemic Agents used for

Type 2 Diabetes Mellitus
Biguanides
Metformin (Glucophage , Glucophage XR)
Action: Decreases the production of glucose by the liver and
increases insulin sensitivity (decreasing insulin resistance).

Nursing Considerations
Renal issues dictate that metformin to be discontinued
Usually discontinued during acute hospitalization
Must be discontinued up to 48 hours before and for 48
hours after diagnostic imaging and anesthesia due to risk of
renal failure
Diarrhea is a common side effect, should be taken with food
Usually taken 1-2 times per day (XR is once per day and
may help with GI symptoms)
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Oral Hypoglycemic Agents used for

Type 2 Diabetes Mellitus
DPP-4 Inhibitors
Sitagliptin (Januva)
Saxagliptin (Onglayza)
Action: Prevent the breakdown of GLP-1. GLP-1
reduces blood glucose levels in the body, but is very
quickly broken down. By interfering in the
breakdown of GLP-1, DDP-4 inhibitors allow it to
remain active longer, lowering blood glucose levels
only when they elevated.

Nursing Considerations:
Do not tend to cause weight gain
Neutral or positive effect on cholesterol.
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Oral Hypoglycemic Agents used for

Type 2 Diabetes Mellitus
Meglitinides
Repaglinide (Prandin)
Nateglinide (Starlix)
Action: Stimulate the beta cells of the pancreas to release insulin
Nursing Considerations:
Taken before all 3 meals
Can cause hypoglycemia

Alpha-glucosidase inhibitors
Acarbose (Precose)
Meglitol (Glycet)
Action: Blocks the breakdown of starches in the intestine, slowing
carbohydrate metabolism and delaying glucose absorption
Nursing Considerations:
Taken with the first bite of a meal
Side effects include gas and diarrhea
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Oral Hypoglycemic Agents used for

Type 2 Diabetes Mellitus
Thiazolidinediones
Rosiglitazone (Avandia) (Black box FDA2011cardiovascular events)
Pioglitazone (ACTOS) (Black Box FDA2011use >1 year bladder CA)
Action: Decrease glucose production in the liver and help insulin work
better in the muscle and fat.
Nursing Considerations:
Monitor liver function closely
Can increase risk of heart failure
Effective in reducing A1C levels

D-Phenylalanine (Amino Acid) Derivative

These drugs work to stimulate rapid and short insulin secretion from
pancreas
Nateglinide (Starlix)

There are other classifications of oral hypoglycemic agents and

new ones being developed in the pipeline.
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Diabetes Mellitus Nutrition

Structured diet to prevent hyperglycemia
Goals
Achieve and maintain normal blood glucose levels
Achieve and maintain optimal serum lipid levels to
reduce the risk of vascular disease
Achieve and maintain blood pressure levels in the
normal range
Prevent or slow rate of development of chronic
complications of DM thru nutrient intake and
lifestyle
Address individual nutrition needs
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Diabetes Mellitus Nutrition

Carbohydrates (4 kcal/gram)
Recommended allowances 45-65% of daily diet

Proteins (4 kcal/gram)
Recommended allowances 15-20% of daily diet

Fats (9 kcal/gram)
No higher than 10%

Fiber
Sodium
Avoid table salt and processed foods

Sweeteners
Educate on terminology of sugar free and dietetic
Kcal similar to table sugar

Alcohol

Not encouraged, but not prohibited

May increase hypoglycemic effects of insulin and oral agents
Must count as food intakefat exchanges
Light beer is recommended alcoholic drink

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Diabetes Mellitus Nutrition

Meal Planning
Numerous systems available
Consistent-Carbohydrate
1 unit of regular insulin or insulin lispro for each 10-15 g of
carbohydrate at each meal.

Exchange Lists
Prescribes how many exchanges are allowed for each food
group per meal and snacks

Diet Plan for Type 1 DM

Diet Plan for Type 2 DM
3 meals of equal size and 1-2 snacks; decrease fat intake.

Diet Plan for Older Adult

Age related decline in kcal requirements
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Diabetes Mellitus
Sick Day Management (Home)
When patient with DM is ill or sick
Blood sugar levels increase, even though food intake decreases
Person mistakes alters or omits the insulin dose which causes
further problems
Focus to prevent dehydration and providing nutrition for promoting
recovery
General guidelines

Monitor blood glucose 4 times/day

Test urine for ketones (type 1)
Continue usual insulin or oral hypoglycemia agents
Sipping 8-12 ounces of fluid/hour
Substitute easily digested foods
Call health care provider if unable to eat for more than 24 hours or if
vomiting and diarrhea last more than 6 hours or develop ketones in urine for
type 1
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Diabetes Mellitus
Sick Day Management (Hospitalization)
When patient with DM is sick or has surgery
Type 1
Insulin control
Basal, Bolus and Correction

Type 2
May discontinue oral agents
Depends upon previous exposure to insulin as to sliding scale orderedlow,
medium or high
May be prescribed basal insulin if correction is not maintaining good glucose
control

General Considerations

IV for hydration
Monitor of ketones for type 1 DM
Increase glucose monitoring frequency
May institute insulin drip for tight glucose control
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Diabetes Mellitus
Exercise
Regular exercise of at least 150 minutes/week
Benefits same as for everyone
Should consult health care provider before beginning
or changing an exercise program
May decrease need for insulin
Or increase food intake

Use proper footwear

Inspect feet daily and after exercise
Avoid exercise in extreme heat or cold
Monitor glucose levels
Prevent dehydration
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Diabetes Mellitus
Surgery
Treatments
Surgically revising GI tract
Replace or transplant pancreas, pancreatic cells or beta cells

Surgery Considerations
Stressor that alters self-management and glucose control in
persons with DM
Increased risk for post-operative infection
Delayed wound healing
Fluid and electrolyte imbalances
Hyperglycemia and hypoglycemia
DKA and HHS
NPOmonitor glucose levels; may need IV glucose and insulin.
Surgical procedure scheduled as early as possible
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Diabetes Mellitus Acute

Complications
Hyperglycemia
Diabetic ketoacidosis (DKA)
Hyperosmolar hyperglycemic state (HHS) may also be
referred to as HHNK (hyperosmolar hyperglycemic nonketotic)
Dawn Phenomenon
Rise in blood glucose between 4-8 AM, that is not in response to an
hypoglycemia incident
Cause unknown but may be linked to nocturnal increase in growth
hormone

Somogyi Phenomenon
Combination of hypoglycemia during the night with a rebound
morning rise in blood glucose to hyperglycemia levels.
May be a cause of insulin resistance. To determine which
phenomenon 3 AM blood glucoses are obtained.
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Diabetes Mellitus Acute

Complications
Diabetic ketoacidosis (DKA)
Primarily seen with type 1 DM
Infection primary cause
Other causes: illness, those who decrease or omit
insulin doses, physical or emotional stress.

Four metabolic problems

Hyperosmolarity from dehydration and
hyperglycemia
Metabolic acidosis from accumulation of ketoacids
Extracellular volume depletion from osmotic diuresis
Electrolyte imbalances
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Diabetes Mellitus Acute

Complications
Diabetic ketoacidosis (DKA)
Manifestations result from severe dehydration and acidosis
Thirst
Warm, dry skin
Soft eyeballs
Dry mucous membranes
Hypotension
Weakness, malaise
Rapid, weak pulse
Nausea and vomiting
Ketone breath (fruity, alcohol-like)
Lethargy to coma
Abdominal pain
Kussmauls respirations (increased rate and depth with long expiration)

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Diabetes Mellitus Acute

Complications
Diabetic ketoacidosis (DKA)
Blood glucose > 250 mg/dL
Plasma pH less than 7.35
Plasma bicarbonate less than 15 mEq/L
Presence of serum ketones
Presence of urine ketones and glucose
Abnormal levels of serum sodium,
potassium and chloride
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Diabetes Mellitus Acute

Complications
Treatment of Diabetic Ketoacidosis (DKA)
Usually requires admission to hospital if blood glucose >250
and decrease pH and + ketones
Alert and oriented
Oral fluid replacement

Others may require IV fluid replacement

Normal saline (0.9% sodium chloride) high rates; may be switched to normal
saline (0.45% sodium chloride) when glucose levels less than 250 mg/dL may
require addition of glucose to IV fluids

Regular insulin depending upon severity of ketones: IVP or insulin gtt or

subcutaneous if ketones only mild
Must watch potassium levelsevery 2-4 hrs along with cardiac
monitoring
Due to acidosis, K levels may be elevated or normal, but due to
extreme diuresis and when pH levels are corrected patient may
develop severe hypokalemia due to the potassium being pushed back
into the cell.
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Diabetes Mellitus Acute

Complications
Hyperosmolar Hyperglycemic State (HHS)
Occurs in people with type 2 DM
Plasma osmolarity > 340 mOsm/L
Greatly elevated blood glucoses
Altered level of consciousness
Serious, life threateningHigher mortality rate
than DKA
Most common cause: infection
Other causes: agents that cause hyperglycemia,
therapeutic procedures, acute and chronic
illnesses.
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Diabetes Mellitus Acute

Complications
Hyperosmolar Hyperglycemic State (HHS)
Manifestations
Initiated by hyperglycemia and increase in urine output
Plasma volume decreases and glomerular filtration
decreases
Glucose is retained and water is loss
Glucose and sodium accumulate in the blood and increase
serum osmolarity.
Severe dehydration
Dry skin and mucous membranes
Extreme thirst
Altered level of consciousness (lethargy to coma)
Neurological deficits
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Diabetes Mellitus Acute

Complications
Treatment of Hyperosmolar Hyperglycemic State
(HHS)
Correct fluid and electrolyte imbalances
Lower blood glucose levels with insulin
Identify and treat the underlying cause
Establish and maintain adequate ventilation
Correct shock with adequate IV fluids
Possible NG to prevent aspiration
Administer potassium with IV to replace losses
Administer insulin to reduce blood glucoses, when
blood glucose reaches ~250 mg/dLinsulin is usually
discontinued and then given as corrective doses (SQ)
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Diabetes Mellitus Acute

Complications
Hypoglycemia (AKA insulin shock, insulin reaction)

Results from too much insulin or oral agent

Physical activity
Lack of carbohydrate availability (skipping meals)
Intake of alcohol or other drugs
Manifestations result from compensatory autonomic nervous
system response and impaired cerebral function.
Usually blood glucose <45-60
Severe hypoglycemia may cause death
Type 1 DM patients can develop a syndrome called
hypoglycemia unawarenessdoes not experience s/s of
hypoglycemiadelays treatment and may have episodes of
severe hypoglycemia or death

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Diabetes Mellitus Acute

Complications
Hypoglycemia (AKA insulin shock, insulin
reaction)
Manifestations

Hunger
Nausea
Anxiety
Pale, cool skin
Sweating
Shakiness
Irritability
Rapid pulse
Hypotension
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Diabetes Mellitus Acute

Complications
Hypoglycemia (AKA insulin shock, insulin
reaction)
Manifestations

Strange or unusual feelings

Headache
Difficulty in thinking
Inability to concentrate
Change in emotional behavior
Slurred speech
Blurred vision
Decreasing levels of consciousness
Seizures
coma
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Diabetes Mellitus Acute

Complications
Hypoglycemia Treatment
Mild hypoglycemia
15 grams of rapid acting sugar

4
3
8
5
3

ounces of regular fruit juice or carbonated beverage

glucose tables
ounces of skim milk
life saver candies
teaspoons of sugar or honey

If symptoms continuerecheck glucose in 15 minutes then eat

another 15 g of carbohydrate continue until glucose >70
mg/dL
Recheck glucose levels in one hourhypoglycemia may return
If hypoglycemia occurs 2-3 times/weekreevaluate
management plan

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Diabetes Mellitus Acute

Complications
Hypoglycemia Treatment
Severe hypoglycemia may be hospitalized if:

Blood glucose less than 50 mg/dL

Patient displays coma, seizures or altered behaviors
If a responsible adult is not available to stay with the patient
If hypoglycemia was due to sulfonylurea drug

If alert and consciousoral carbohydrate given and

follow mild hypoglycemia dosing
If altered consciousnessparenteral glucose 50 mL of
dextrose 50% (D50) or glucagon (1 mg subcutaneous,
intramuscular or intravenous push) is administered
If patient is unconsciousglucagon may cause patient to
vomit when consciousness returns
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Diabetes Mellitus
Chronic Complications
Chronic complications
Alterations in the cardiovascular system
Coronary artery disease
Hypertension
Stroke (cerebrovascular accidentCVA)

Peripheral Vascular disease

Lower extremities
Intermittent claudication
Ulcers of the feet
Neurological impairment
infections
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Diabetes Mellitus
Chronic Complications
Diabetic Retinopathy
Changes in the retina
Leading cause of blindness for 24-74 year olds
Screening is importantlaser photocoagulation
surgery is beneficial to decrease loss of vision

Diabetic Nephropathy
Kidney disease characterized by albumen in urine
Leads to end stage renal failure and requirement
of dialysis
Hypertension accelerates diabetic nephropathy

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Diabetes Mellitus
Chronic Complications
Alterations in the peripheral and autonomic
nervous systems know as Diabetic neuropathies
Peripheral
Bilateral sensory disorders
First in toes and feet and progress upward
May affect fingers and hands but in later stages of DM
Distal paresthesias (change in sensation, numbness or
tingling)
Painaching, burning and shooting
Feelings of cold feet
Impaired sensations of pain, light touch and vibration
Result in lack of sensation prevents awareness of injury
Educate to look at feet and legs for injury on daily basis

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Diabetes Mellitus
Chronic Complications
Alterations in the peripheral and autonomic
nervous systems know as Diabetic
neuropathies
Visceral Neuropathies
Sweating dysfunction
Absence on hands and feet
Increased on face or trunk

Abnormal pupillary function

Constricted pupils that dilate slowly in the dark

Cardiovascular dysfunction
Fixed heart rate that doesnt change with exercise, postural
hypotension, failure to increase cardiac output with exercise

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Diabetes Mellitus
Chronic Complications
Alterations in the peripheral and autonomic nervous
systems know as Diabetic neuropathies
Gastrointestinal dysfunction
Gastroparesischange in upper GI motility
Dysphagia, anorexia, heartburn, nausea and vomiting
Metoclopramide (Reglan) given before mealspromotility
agent
Constipation

Genitourinary dysfunction
Changes in bladder function
Inability to empty bladder or loss of sensation of fullness
Increase risk for UTI
Changes in sexual function
Ejaculatory changes and impotence for men
Changes in arousal patterns, vaginal lubrication for female
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Diabetes Mellitus
Chronic Complications
Mood alterations
Chronic strain of living with complex self care
Increased risk for depression

Increased susceptibility to infections

Vascular and neurological impairments

Hyperglycemia
Altered neutrophil function
Surgical patients with DM higher infection rates

Periodontal disease
Progresses more rapidly with patients with DM
Gingivitis (inflammation of gums)
Periodontitis (inflammation of the bone)
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Diabetes Mellitus
Chronic Complications
Complications involving the feet
Increase incidence of amputations and problems with the
feet
Vascular changes in lower extremities
Manifestations of peripheral vascular disease
Diabetic neuropathy
Foot trauma without being aware

Cracks and fissuresdry skin or athletes foot infections

Blisters from improper fitting shoes
Ingrown toe nails
Direct traumacuts, bruises and/or burns
Small superficial skin ulcer can rapidly extend deeper into
muscle and bone, leading to abscess or osteomyelitis
Gangrene may developmay lead to amputation
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Diabetes Mellitus
Nursing Care
Education and Self-Care Vital to Prevent
complications and improve quality of life
Newly diagnosed patient with DM
Person with long-term DM
Person with acute complications related to
DM
Plan of care is individualized
All nursesgeneralists and DM specialists
must provide education and support
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Diabetes Mellitus
Nursing Care
Health Promotion

Prevent onset and complications of DM

Prevention of type 2 DM
Lifestyle changes
Blood glucose screening at 3 year intervals
beginning at age 45 is recommended for
those not in high risk group
Hgb A1C and Fasting Blood Glucoses

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Diabetes Mellitus
Nursing Care
Nursing Diagnoses and Interventions

Risk for impaired skin integrity

Risk for Infection
Risk for Injury
Sexual Dysfunction
Ineffective Coping
Deficient Knowledge: medications
Deficient Knowledge: foot care
Deficient Knowledge: Decreasing likelihood of complications

Nursing Care
Outcomes and Evaluations

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