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DIABETES MELLITUS
DEFINITION.
A syndrome characterized by disordered
metabolism and inappropriately high
blood sugar (hyperglycaemia) resulting
from either low levels of the hormone
insulin or from abnormal resistance to
insulin’s effects coupled with inadequate
level of insulin secretion to compensate.
CLASSIFICATION OF
DIABETES MELLITUS.
♦ TYPE 1
♦ Characterized by loss of the insulin-
producing beta cells of the islets of
langerhans in the pancreas ,leading to a
deficiency of insulin.
♦ The main cause of this beta loss is a T- cell
mediated autoimmune attack.
CON’T…
♦ TYPE 2
♦ Due to insulin resistance or reduced insulin
sensitivity,combined with reduced insulin
secretion.
♦ The defective responsiveness of body tissues to
insulin almost certainly involves the insulin
receptor in cell membranes.
♦ In the early,stage the predominant abnormality is
reduced insulin sensitivity,characterized by
elevated levels of of insulin in the blood.
PATHOPHYSIOLOGY
♦ Glucose is an essential nutrient that provides
energy for the proper functioning of the body
cells.
♦ The glucose in digested food is absorbed by the
intestinal cells into the bloodstream and is carried
by blood to all the cells in the body.
♦ However glucose cannot enter the cells alone.It
needs assistance from insulin in order to
penetrate the cell walls.
CON’T…
♦ Insulin therefore acts as a regulator of glucose
metabolism in the body.
♦ Insulin is called the “hunger hormone”.As the
blood sugar level increases following a
carbohydrate rich meal,the corresponding insulin
level rises with the eventual lowering of the
blood sugar and glucose is transported from the
blood into the cell for energy.
♦ When the blood glucose levels are lowered,the
insulin release from the pancreas is turned off.
CON’T…
♦ When the blood sugar level drops below a
certain level,hunger is felt.This often occurs
a few hours after the meal.
♦ In normal individuals,such a regulatory
system helps to keep blood glucose levels in
a tightly controlled range.
♦ Cravings for sweets frequently form part of
ths cycle,which can lead to snacking ,often
for more carbohydrates.
CON’T…
♦ If the cravings are not fulfilled,sensations such as
hunger,dizziness,moodiness and a state of “collapse” can
result.
♦ This system of auto regulation and homeastasis is the funtion
of the pancreas and it works around the clock.
♦ Dysfunction of this auto regulation system-either inability of
the pancreas to secrete any or insufficient insulin or pancreas
overload from much sugar ingested over a long period of
time or over compensatory mechanism or a combinationof
these results in the lack of insulin and hence high blood
sugar.
ETIOLOGY
♦ Obesity(overweight)
♦ Waist size
♦ Sedentary lifestyle
♦ Age
♦ Family history
♦ Ethnicity
♦ Pre-diabetes
♦ Gestational diabetes/high birth weight baby
♦ High blood pressure/cholesterol
CLINICAL MANIFESTATION
♦ Polyuria(excessive urination)
♦ Polydipsia(exssive thirst)
♦ Excessive hunger
♦ Fatigue
♦ Blurry vision
♦ Polyphagia
♦ Smell of acetone the patients breath
♦ A rapid,deep breathing(kuss maul breathing)
♦ Lethargy
♦ Recurrent infection
CON’T…
♦ Vulvovaginitis
♦ Pruritis
♦ Nocturia
♦ Nonspecific instability of balance
♦ Nausea
♦ Vomiting
♦ Abdominal pain
♦ Weakness
♦ dizziness
♦ Confusion
INVESTIGATIONS
 Fasting blood sugar
 Casual blood glucose
 Postload blood glucose
 Glycosylated hemoglobin
 Glycosylated albumin
 OGGT(Oral glucose tolerance test)
 Ketonuria
 proteinuria
TREATMENT
(1)Gliclazide
Trade name:diamicron
Route:40-80mg daily
Indications:diabetes mellitus
Side effects:nausea,headache,rashes,GI disturbance.
(2)Chlorpropamide
Trade name:diabenese
Route:250-500mg daily
Indications:diabetes mellitus,
Side effects:jaundice,disulfiram-like reactions
CON’T…
(3)Glibenclamide
Trade name:daonil,euglucon
Route:2.5-15mg dly.(with or immediately after breakfast)
Indications:diabetes mellitus,diabetic coma,renal
impairment,pregnancy.
Side effects:GI disturbance,blood dyscrasia.
(4)Glimepiride
Trade name:amaryl
Route:1mg dly adjusted according to response)
Indications:diabetes mellitus
Side effects:regular hepatic
CON’T…
(5)Glipizide
Trade name:glibenese,minodiab
Route:2.5-5mg dly adjusted according to response
Indications:diabetes mellitus
Side effects:dizziness,drowsiness.
(6)Tolbutamide
Trade name:tolbutamide
Route:0.5-1.5mg after breakfast
Indications:diabetes mellitus
Side effects:headache,tinnitus
CON”T…
(7)Melformin hydrochloride
Trade name:glucophage
Route:500mg tds,or 850mg 12 hrly with food.
Indications:diabetic coma,
Side effects:anorexia,nausea,vomiting,diarrhoea
(8)Acarbose
Trade name:glucobay
Indications:controlled by diet or by diet hypogalcemia
agents
Side effects:soft stool,abdominal didtention and pain
CON’T…
(9)Insulin recombinant neutral human
Trade name:actrapid
Route:dose to be individualised
Side effects:rare incidence or allergy
(10)Insulin recombinant synthetic human
Trade name:insulatard
Route:dose to be individualised
Side effects:rare incidence,or allergy
NURSING MANAGEMENT
 Self management and to become the focus of the
team approach to treatment.
 Assessment of the clients level of a acceptance of
personal responsibility is necessary.
 Administer medications(oral antidiabetes,insulin
theraphy).
 Balancing diet,exercise
 Promote proper nutrion to improve metabolic
control.
 Change in eating habis or patterns.
COMPLICATION
 Eye complications(diabetic retinopathy)
 Kidney damage(kidney disease)
 Nerve damage
 Heart disease
 Stroke(brain attack)
 Urinary incontinence(unable to hold urine)
 Intestinal distruptions leading to constipation.
PATIENT PROFILE
 Patient x
 78 year
 Rh,kian tg,bijat sri aman
 653/08
 300105-13-5054
 Female
 Iban(kristian)
 Married
 House wife
 Malaysian
NURSING PROGRESS NOTE
PM DUTY(17/2/08)
Whell chair case,warded at 5.55pm via A&E.
On admission,patient concious and alert.
V/S:BP:120/80-160/80
PR:86/min
TEMP:36.5’C-37’C
Tablet Gliclazide 160mg
Tablet Haemotinics
Tablet Prosojin 1mg
Tablet DITP 50mg
(served at 6.30pm)
Taken food from home
CON’T…
NPO/BNO since on admission.
G/C;Fair
Treatment
Tab.Adalat 10mg
HPC(hypocount)
Tab.Lovastatin 20mg
(due at 10pm)
IVF 3%saline in progress due at 6pm(18/2/08)
NURSING PROGRESS NOTE
ND(17/2/08)
Hpc:11.4mmol
Tab.Adalat 10mg
Tab.Lovastatin 20 mg
(due at 10pm)
Tab.Ferrous Fumarate 200mg
Tab.Folic Acid 1/1
Mist Nacl 2g
Tab Metaprolol 50mg
Tab Prazogin 1mg
(served at 5am)
CON’T…
Hpc:5.3mmol
BUSE and UFEME taken.
Patient afebril
BP:140/80-120/80 mmHg
PR:84min
Urine output:280cc Oral intake:150cc
Treatment:IV drip 3% n/s in progress on due
3pm(18/2/08)
NURSING PROGRESS NOTE
AM(18/2/08)
Mist.carbinative 15mls served at 8.45pm.
Temperature:normal
BP:120/60-130/60
Still complain of weakness&sight giddiness
Adu RIB
11.20am HPC:18.8 mmol(after lunch)
Taken 1 plate of rice for lunch
I/O:300/300 BNO
CON’T…
Tab.Ferrous Fummerate 200mg
Mist Nacl 2gm
Tab Adalat 10mg
(served at 11.00am)
G/C;Fair
Treatment
-IVF 3% saline in progress due at 4pm
-Repeat BUSE at 4pm
NURSING PROGRESS NOTE
PM(18/2/08)
Temp:afebrile
BP:145/70-150/80 mmHg
PR:75-70min
Repeat BUSE taken@4pm-result seen by Dr a(to continue 1
more pint 3% saline over 24 hour.to repeat BUSE at 5pm
after complete 3% saline)
Mist Nacl 2gm
Mist Carbinative 15mls
Tab.Gliclazide 160mg
Tab.Metropolol 50mg
Tab.Prazogin 1mg
CON’T…
Dinner taken
Pass urine
I/O recorded
G/C:Fair
NURSING PROGRESS NOTE
ND(18/2/08)
Mist Nacl 2g
Tab.Lovastatin 20mg
Tab.Adalat 10mg
Tab Prazogin 1mg
Tab Metropolol 50mg
Tab Gliclazide 160mg
Mist carminative
Tab Ferrous Fummerate 1/1
Tab Folic Acid
CON’T…
Patient afebrile
BP:120/70-130/70mmHg
I/O;650CC-1200CC
HPC:10.6mmol
Sleep well
Taken breakfast
NURSING PROGRESS NOTE
AM(19/2/08)
Patient”s vital sign stable
Nil new complaint
Fit for discharge today
Adu on (A) given
Home at 11.30 am
NURSING CARE PLAN
(1) Anxiety related to hospitalization.
Goal
-Patient will verbalise less anxiety
Intervention:
-assess patients level of a anxiety
-explain to patients the important of completing the
treatment.
-explain to patients regarding procedures.
-give emotional support.
-involve patients when planning nursing care.
Cont’s…
♦ Evaluation:
-patient describes at least two situations that
increase tension.
-patient states at least two ways to eliminate
or minimize anxious behaviors.
-patient reports being able to cope with
current situation without experiencing
severe anxiety.
Cont’s…
(2)Ineffecive health maintenance related to
management of type 1 diabetes mellitus.
Goal:
-patients will describes feeling about self
management of types1 diabetes mellitus.
-patients will describes disease process.
Interventions:
-evaluate the patients understanding of types1
diabetes mellitus and attitude about the need to
manage it.
Cont’s…
-correct any misconceptions about type 1 diabetes
mellitus and the therapeutic regimen.
-discuss peer presure.ask the adolesent if patients feel
social pressure that causes to ignore dieter avoid self
administering insulin.
-ask if patients feel eparrassed about disorder.
Evaluations:
-patients express feelings about self management of
diabetes mellitus.
-patients accurately describes disease process of type 1
diabetes mellitus.
Cont’s…
(3)Nutrition less than body requirements relaed to
poor of appetite.
Goal:
-patients will show no futher evidence of weigth loss.
-patients will take in calories daily.
Interventions:
-obtain and record patients weight at the same time
every day to obtain accurate readings.
Cont’s…
(4)Risk for fluid volume deficit related to
hyperglycaemia and osmotic diuresis.
Goal:
-The diabetic client will exhibit optima fluid
balance as evidence by:
#Blood pressure > 90/60mmHg (or within
the client normal range).
#Firm skin torgor and moist mucous
membranes.
Cont’s…
-maintain parental fluids or ordered to provide
patiens with needed fluids and electrolytes.
-monitor electrolytes level and report
abnormal values.
Evaluations:
-patients remains at or above specified weight.
-patients consumes specified number of
calories daily.
Cont’s…
Intervention:
-Monitor vital signs every 15min until the
client condition is stable for 1hour,then 4
hourly.
-Notify the physician if heart rate is >
120/min,blood pressure is <90/60mmHg or
decreased >20mmHg from baseline, MAP is
decreased >10mm from baseline, CVP is
<2mmHg and <6mmHg.
Cont’s
-Monitor the client for fluid volume deficit:
poor skin turgor, dry mucus membranes
sunken and soft eyeballs.
-Measure intake and output accurately: report
to the physician urine output <30ml /hour
for 2 consecutive hours.
-Weight the client daily on the same scales.
-Administer IV fluid as described.
Con’t…
-Administer antiemetic medications to the
client as prescribed.
-unless contraindicated,maintain oral intake of
at least 2500ml.
HEALTH EDUCATIONS
Advice the patients:
-Avoid adding sugar to foods such as coffee
and cereal.
-Avoids food that are sweetened with sugar or
honey,such as jellies,jams,cakes,and ice-
cream.
-Check blood glucose level regularly.
-Limit intake of saturated fat and cholesterol
in food.
Cont’s…
-Keep periodic appointment with health care
providers for evaluation of bloods glucose
control.
-Be consistent about the amount,distribution
and timing of nutrients.
-Increase the amount of carbohydrate in a
meal eaten before sustained exercise.
SUMMARY
Madam X admission on 17/3/2008.Was
given IVF 3% Normal Saline 1pint 24
hours,Tablet Metaprolol 50g bd,Tablet
Nifedipine 10g bd,Tablet Glicazide 160g
bd,Tablet Pzayosin 1mg bd.Upon discharge
on 19/3/2008 afebrile,vital sign
stable,hypocount 5mmo/L.Patient has no
hypoglycaemia or hyperglycaemia,attack or
other complaint made.general condition
satisfactory.