DIABETES MELLITUS

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin
or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be
absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive
thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases,
daily injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or adult-
onset diabetes, and this form of diabetes occurs most often in people who are overweight and
who do not exercise. Type II is considered a milder form of diabetes because of its slow onset
(sometimes developing over the course of several years) and because it usually can be
controlled with diet and oral medication. The consequences of uncontrolled and untreated Type
II diabetes, however, are the just as serious as those for Type I. This form is also called
noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with Type II
diabetes can control the condition with diet and oral medications, however, insulin injections are
sometimes necessary if treatment with diet and oral medication is not working.

The causes of diabetes mellitus are unclear, however, there seem to be both hereditary
(genetic factors passed on in families) and environmental factors involved. Research has shown
that some people who develop diabetes have common genetic markers. In Type I diabetes, the
immune system, the body’s defense system against infection, is believed to be triggered by a
virus or another microorganism that destroys cells in the pancreas that produce insulin. In Type
II diabetes, age, obesity, and family history of diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells have
become resistant to the insulin produced and it may not work as effectively. Symptoms of Type
II diabetes can begin so gradually that a person may not know that he or she has it. Early signs
are lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight
loss, slow wound healing, urinary tract infections, gum disease, or blurred vision. It is not
unusual for Type II diabetes to be detected while a patient is seeing a doctor about another
health concern that is actually being caused by the yet undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include people who:

 are obese (more than 20% above their ideal body weight)
 have a relative with diabetes mellitus
 belong to a high-risk ethnic population (African-American, Native American, Hispanic, or
Native Hawaiian)
 have been diagnosed with gestational diabetes or have delivered a baby weighing more
than 9 lbs (4 kg)
 have high blood pressure (140/90 mmHg or above)
 have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a
triglyceride level greater than or equal to 250 mg/dL
 have had impaired glucose tolerance or impaired fasting glucose on previous testing

Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle
changes. It is best managed with a team approach to empower the client to successfully
manage the disease. As part of the team the, the nurse plans, organizes, and coordinates care
among the various health disciplines involved; provides care and education and promotes the
client’s health and well being. Diabetes is a major public health worldwide. Its complications
cause many devastating health problems.

ANATOMY AND PHYSIOLOGY:

Every cell in the human body needs energy in order to function. The body’s primary energy
source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates
(sugars and starches). Glucose from the digested food circulates in the blood as a ready energy
source for any cells that need it. Insulin is a hormone or chemical produced by cells in the
pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside
of cell and acts like a key to open a doorway into the cell through which glucose can enter.
Some of the glucose can be converted to concentrated energy sources like glycogen or fatty
acids and saved for later use. When there is not enough insulin produced or when the doorway
no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.
PATHOPHYSIOLOGY:

DIAGNOSTIC TEST:

Several blood tests are used to measure blood glucose levels, the primary test for diagnosing
diabetes. Additional tests can determine the type of diabetes and its severity.

 Random blood glucose test — for a random blood glucose test, blood can be drawn at
any time throughout the day, regardless of when the person last ate. A random blood
glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of
high blood glucose suggests a diagnosis of diabetes.
  Fasting blood glucose test — fasting blood glucose testing involves measuring blood
glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting
blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL (7.0
mmol/L) or higher indicates diabetes. The test is done by taking a small sample of blood
from a vein or fingertip. It must be repeated on another day to confirm that it remains
abnormally high.

 Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose
level during the past two to three months. It is used to monitor blood glucose control in
people with known diabetes, but is not normally used to diagnose diabetes. Normal
values for A1C are 4 to 6 percent. The test is done by taking a small sample of blood
from a vein or fingertip.

 Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) is the most
sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not
routinely recommended because it is inconvenient compared to a fasting blood glucose
test.

The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram
liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two
hours later, a second blood glucose level is measured.

Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen

for gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose
level drawn one hour later. For women who have an abnormally elevated blood glucose level, a
second OGTT is performed on another day after drinking a 100 gram glucose solution. The
blood glucose level is measured before, and at one, two, and three hours after drinking the
solution.

MEDICATIONS:

When diet, exercise and maintaining a healthy weight aren’t enough, you may need the help of
medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes
and some people with type 2 diabetes must take insulin every day to replace what their
pancreas is unable to produce. Unfortunately, insulin can’t be taken in pill form because
enzymes in your stomach break it down so that it becomes ineffective. For that reason, many
people inject themselves with insulin using a syringe or an insulin pen injector,a device that
looks like a pen, except the cartridge is filled with insulin. Others may use an insulin pump,
which provides a continuous supply of insulin, eliminating the need for daily shots.

The most widely used form of insulin is synthetic human insulin, which is chemically identical to
human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isn’t
perfect. One of its chief failings is that it doesn’t mimic the way natural insulin is secreted. But
newer types of insulin, known as insulin analogs, more closely resemble the way natural insulin
acts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine
(Lantus).

A number of drug options exist for treating type 2 diabetes, including:

· Sulfonylurea drugs. These medications stimulate your pancreas to produce and release
more insulin. For them to be effective, your pancreas must produce some insulin on its own.
Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta,
Glynase PresTab, Micronase) and glimepiride (Amaryl) are prescribed most often. The most
common side effect of sulfonylureas is low blood sugar, especially during the first four months of
therapy. You’re at much greater risk of low blood sugar if you have impaired liver or kidney
function.

· Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to

sulfonylureas, but you’re not as likely to develop low blood sugar. Meglitinides work quickly, and
the results fade rapidly.

· Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class available
in the United States. It works by inhibiting the production and release of glucose from your liver,
which means you need less insulin to transport blood sugar into your cells. One advantage of
metformin is that is tends to cause less weight gain than do other diabetes medications.
Possible side effects include a metallic taste in your mouth, loss of appetite, nausea or vomiting,
abdominal bloating, or pain, gas and diarrhea. These effects usually decrease over time and are
less likely to occur if you take the medication with food. A rare but serious side effect is lactic
acidosis, which results when lactic acid builds up in your body. Symptoms include tiredness,
weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is especially likely to occur
if you mix this medication with alcohol or have impaired kidney function.

· Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive
tract that break down carbohydrates. That means sugar is absorbed into your bloodstream more
slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal.
Drugs in this class include acarbose (Precose) and miglitol (Glyset). Although safe and
effective, alpha-glucosidase inhibitors can cause abdominal bloating, gas and diarrhea. If taken
in high doses, they may also cause reversible liver damage.

· Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and keep
your liver from overproducing glucose. Side effects of thiazolidinediones, such as rosiglitazone
(Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight gain and fatigue. A
far more serious potential side effect is liver damage. The thiazolidinedione troglitzeone
(Rezulin) was taken off the market in March 2000 because it caused liver failure. If your doctor
prescribes these drugs, it’s important to have your liver checked every two months during the
first year of therapy. Contact your doctor immediately if you experience any of the signs and
symptoms of liver damage, such as nausea and vomiting, abdominal pain, loss of appetite, dark
urine, or yellowing of your skin and the whites of your eyes (jaundice). These may not always be
related to diabetes medications, but your doctor will need to investigate all possible causes.

· Drug combinations. By combining drugs from different classes, you may be able to control
your blood sugar in several different ways. Each class of oral medication can be combined with
drugs from any other class. Most doctors prescribe two drugs in combination, although
sometimes three drugs may be prescribed. Newer medications, such as Glucovance, which
contains both glyburide and metformin, combine different oral drugs in a single tablet.

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