Diabetes mellitus is a group of mtabolic disorders characterized by elevated levels of blood glucose (hyperglycemia) resulting from defects in insulin production and secretion, decreased cellular response to insulin, or both. Hyperglycemia may lead to metabolic complications, such as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Long-term hyperglycemia may contribute to chronic microvascular complications (kidney and eye disease) and neuropathic disease. Diabetes is also associated with an increased occurrence of macrovascular disease, including coronary artery disease (myocardial infarction), cerebrovascular disease (stroke), and peripheral vascular disease.
Types of Diabetes
Type 1 (Formerly Insulin-Dependent Diabetes Mellitus)
- About 5% to 10% diabetic patients have type 1 diabetes. Beta cells of the pancreas that normally produce insulin are destroyed by autoimmune process. Insulin injections are needed to control the blood glucose levels.
- Type 1 diabetes has a sudden onset, usually before the age of 30 years.
Type 2 (Formerly Non-Insulin-Dependent Diabetes Mellitus)
- About 90% to 95% of diabetics have type 2 diabetes. It results from a decreased sensitivity to insulin ( insulin resistance) or from a decreased amount of insulin production.
- Type 2 diabetes is first treated with diet and exercise, then oral hypoglycemic agents are needed.
- Type 2 diabetes occurs more frequently in patients older than 30 years of age and in obese patients.
- Gestational diabetes is characterized by any degree of glucose intolerance with onset during pregnancy (second or third trimester).
- It occurs in women 25 years of age or older, women younger than 25 years of age who are obese, women with a family history of diabetes in first-degree relatives, or members of certain ethnic racial groups (eg, Hispanic American, Native American, Asian American, African American, or Pacific Islander). It increases their risk for hypertensive disorders of pregnancy.
- Polyuria, polydipsia, and polyphagia
- Fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, sores that heal slowly, and recurrent infections.
- Onset of Type 1 diabetes may be associated with nausea, vomiting, or stomach pains
- Type 2 diabetes results from a slow (over years), progressive glucose intolerance and results in long-term complications if diabetes goes undetected for many years (eg, eye disease, peripheral neuropathy, peripheral vascular disease). Complications may developed before the actual diagnosis is made.
- Signs and symptoms of DKA include abdominal pain, nausea, vomiting, hyperventilation, and fruity breath odor. Untreated DKA may result in altered level of consciousness, coma and death
Assessment and Diagnostic Methods
- High blood glucose levels: fasting plasma glucose levels 126 mg/dL or more, or random plasma glucose levels more than 200 mg/dL on more than one occasion.
- Evaluation for complications
For obese patients (especially those type 2 diabetes): weight loss is the key to treatment and the major preventive factor for the development of diabetes.
Complications of Diabetes
Complications associated with both types of diabetes are classified as acute or chronic. Acute complications occur from short-term imbalances in blood glucose and include:
Chronic complications generally occur 10 to 15 years after the onset of diabetes mellitus. They include:
- Macrovascular (large vessels) disease: affects coronary peripheral vascular, and crerbral vascular circulations.
- Microvascular (small vessels) disease: affects the eyes (retinopathy) and kidneys (nephropathy); control blood glucose levels to delay or avoid onset of both microvascular and macrovascular complications.
- Neuropathic disease: affects sensory motor and autonomic nerves and contributes to such problems as impotence and foot ulcers.
Because the incidence of elevated blood glucose levels increases with advance age, elderly adults should be advised that physical activity that is consistent and realistic is beneficial to those with diabetes. Advantages of exercise include a decrease in hyperglycemia, a general sense of well-being, metabolism of ingested calories, and weight reduction. Consider physical impairment from other chronic disease when planning an exercise regimen for elderly diabetic patients.
The main goal of treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications. The therapeutic goal within each type of diabetes is to achieve normal blood glucose levels (euglycemia) without hypoglycemia and without seriously disrupting the patients usual activities. There are five components of management for diabetes: nutrition, exercise, monitoring, pharmacologic therapy, and education.
- Primary treatment of type 1 diabetes is insulin
- Primary treatment of type 2 diabetes is weight loss
- Exercise is important in enhancing the effectiveness of insulin
- Use oral hypoglycemic agents if diet and exercise are not successful in controlling blood glucose levels. Insulin injections may be used in acute situations.
- Because treatment varies throughout course because of changes in lifestyle and physical and emotional status as well as advances in therapy, continuously assess and modify treatment plan as well as daily adjustments in therapy. Education is needed for both patient and family.
- Meal plan should be based on patient’s usual eating habits and lifestyle and should provide all essential food constituents (eg, vitamins, minerals)
- Goals are to achieve and maintain ideal weight, meet energy needs, prevent wide daily fluctuations in blood glucose levels (keep as close to normal as is safe and practical), and decrease blood lipid levels, if elevated.
- For patients who require insulin to help control blood glucose levels, consistency is required in maintaining calories ans carbohydrates consumed at different meals.
- Consult dietitian for diabetes management planning to gradually increase or add fiber in meal plan (grains, vegetables).
- Determine basic caloric requirements, taking into consideration age, gender, weight, and height and factoring in degree of activity (Harris-Benedict formula for basal energy expenditure)
- Long-term weight reduction can be achieved (1 to 2 pound loss per week) by reducing basic caloric intake by 500 to 1000 calories from calculated basic caloric requirements.
- The American Diabetes and American Dietitic Associations recommend that for all levels of caloric intake, 50% to 60% of calories be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Using food combinations to lower glycemic response (glycemic index) can be useful. Carbohydrate counting and the food guide pyramid can be useful tools.
NURSING PROCESS: The Patient with Newly Diagnosed Diabetes Mellitus
- Focus on signs and symptoms of prolonged hyperglycemia and physical, social, and emotional factors hat affect ability to learn and perform diabetes self-care activities.
- Ask for description of symptoms that preceded the diagnosis: polyuria, polydipsia, polyphagia, skin dryness, blurred vision, weight loss, vaginal itching, and nonhealing ulcers.
- Assess for signs of DKA, including ketonuria, Kussmaul respirations, orthostatic hypotension, and lethargy
- Question regarding DKA symptoms of nausea, vomiting and abdominal pain.
- Monitor laboratory signs for metabolic acidosis (decreased pH, decreased bicarbonate) and electrolyte imbalance.
- Assess patients with type 2 diabetes for signs of HHNS, hypotension, altered sensorium, seizures, decreased skin turgor, hyperosmolarity and electrolyte imbalance.
- Assess physical factors that impair ability to learn or perform self-care skills: visual defects, motor coordination defects, neurologic defects
- Evaluate patient’s social situation for factors that influence diabetic treatment and education plan (literacy, financial resources, health insurance, family support); evaluate typical daily schedule (eg, work, meals, exercise, travel plans).
- Assess emotional status through observations of general demeanor (eg, withdrawn, anxious, body language).
- Assess coping skills by asking how patient has dealt with difficult situations in the past.
- Risk for fluid volume deficit related to polyuria and dehydration
- Imbalanced nutrition related to imbalance of insulin, food, and physical activity
- Deficient knowledge about diabetes self-care skills and information
- Potential self-care deficit related to physical impairments or social factors
- Anxiety related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, and fear of diabetes complications
- Risk for complications
Collaborative Problems/Potential Complications
- Fluid overload, pulmonary edema, congestive heart failure
- Hyperglycemia and DKA
- Cerebral edema
Planning and Goals
The major goal of the patient may include attainment of fluid and electrolyte balance, optimal control of blood glucose, regaining weight lost, ability to perform basic (survival) diabetes skills ans self-care activities, reduction in anxiety, and absence of complications.
Maintaining Fluid and Electrolyte Balance
- Measure intake and output
- Administer intravenous fluids and electrolytes as ordered.
- Measure serum electrolytes (sodium, potassium) and monitor closely.
- Monitor vital signs to detect dehydration; tachycardia, orthostatic hypotension
Improving Nutritional Intake
- Plan the diet with glucose control as the primary goal.
- take into consideration patient’s lifestyle, cultural background, activity level, and food preference
- Encourage patient to eat full meals and snacks as per diabetic diet.
- Make arrangements for extra snacks before increased physical activity.
- Ensure that insulin orders are altered as needed for delays in eating due to diagnostic and other procedures
- Provide emotional support; set aside time to talk with patient.
- Clear up misconceptions patient and family may have regarding diabetes.
- Assist patient and family to focus on learning self-care behaviors.
- Encourage the patient to perform skills feared most; self-injection or finger stick glucose monitoring.
- Give positive reinforcement for self-care behaviors attempted.
Monitoring and Managing Potential Complications
- Fluid overload: measure vital signs and monitor central venous pressure (CVP) and total hemodynamic status at frequent intervals; assess cardiac rate and rhythm, breath sounds, venous distention, skin turgor, and urine output; monitor intravenous fluid and other fluid intake.
- Hypokalemia: replace potassium cautiously, ensure that kidneys are functioning before administration; monitor cardiac rate, rhythm, electrocardiogram (ECG), and serum potassium levels
- Hyperglycemia and DKA: monitor blood glucose levels and urine ketones; administer medications (insulin, oral hypoglycemic agents); monitor for signs and symptoms of impending hyperglycemia and DKA, administering insulin and intravenous fluids to correct.
- Hypoglycemia: treat with juice or glucose tablets; encourage patient to eat full meals or snacks as prescribed; review signs and symptoms, possible causes, and measures to prevent or treat.
- Cerebral edema: prevent by gradual reduction in blood glucose level’ monitor blood glucose level, serum electrolyte levels; urine output, mental status, and neurologic signs, minimize activities that increase intracranial pressure.
Joyce Young Johnson et.al Handbook for Brunner & Suddarth’s Textbook for Medical Surgical Nursing 11th edition
Lippincott Williams & Wilkins pp.299-306