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Diabetes Mellitus

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

  • 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.

Clinical Manifestations

  • 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:

  • Hypoglycemia
  • DKA
  • HHNS

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.

Gerontologic Considerations

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.

Medical Management

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.

Nutritional Management

  • 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).

Caloric Requirements

  • 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.


Nursing Diagnoses

  • 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
  • Hypokalemia
  • Hyperglycemia and DKA
  • Hypoglycemia
  • 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.

Nursing Interventions

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

Reducing Anxiety

  • 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 Handbook for Brunner & Suddarth’s Textbook for Medical Surgical Nursing 11th edition

Lippincott Williams & Wilkins pp.299-306




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Cushing’s Syndrome

Cushing’s syndrome results from excessive adrenocortical activity. It may result from excessive administration of corticosteroids or adrenocorticotropic hormone (ACTH) or from hyperplasia of the adrenal cortex. It may be caused by several mechanism, including a tumor in the pituitary gland or less commonly an ectopic malignancy that produces ACTH. Regardless of the  cause, the negative feedback mechanisms that control the functions of the adrenal cortex  become ineffective, resulting in oversecretion of glucocorticoids, androgens, and possibly mineralocorticoid. Cushing syndrome occurs five times more often in women ages 40 to 60 years than in men.

Clinical Manifestations

  • Arrested growth, weight gain and obesity, musculoskeletal changes, and glucose intolerance
  • Classic features: central-type obesity, with a fatty “buffalo hump” in the neck and supraclavicular area, a heavy trunk, and relatively thin extremities; skin is thin, fragile, easily traumatized, with ecchymoses and striae
  • Weakness and lassitude; sleep is disturbed because of altered diurnal secretion of cortisol.
  • Excessive protein catabolism with muscle wasting and osteoporosis; kyphosis, backache, and compression fractures of the vertebrae are possible
  • Retention of sodium and water, producing hypertension and heart failure
  • “Moon-faced” appearance, oiliness of skin and acne
  • Increased susceptibility to infection; slow healing of minor cuts and bruises
  • Hyperglycemia or overt diabetes
  • Virilization in females (due to excess androgens) with appearance of masculine traits and recession of feminine traits (eg; excessive hair on face, breasts atrophy, menses cease, clitoris enlarges, and voice deepens); libido is lost in males and females
  • Changes occur in mood and mental activity; psychosis may develop and distress and depression are common
  • If Cushing’s syndrome is the result of a pituitary tumor, visual disturbances are possible cause of pressure on the optic chiasm

Assessment and Diagnostic Findings

  • Overnight dexamethasone  suppression test to measure plasma corticol level (stress, obesity, depression, and medications may falsely elevate results)
  • Computed tomography (CT) or magnetic resonance imaging (MRI) scan or ultrasound may localize adrenal tissue and detect adrenal tumors

Medical Management

Treatment is usually directed at the pituitary gland because most cases are due to pituitary tumors rather than tumors of the adrenal cortex.

  • Surgical removal of the tumor (transsphenoidal hypophysectomy) is the treatment of choice (90% success rate.
  • Radiation of the pituitary gland is successful but takes several months for symptom control.
  • Adrenalectomy is performed in  patients with primary adrenal hypertrophy
  • Postoperatively, temporary replacement therapy with hydrocortisone may be necessary until the adrenal glands begin to respond normally (may be several months)
  • If bilateral adrenalectomy was performed, lifetime replacement of adrenal cortex hormones is necessary
  • Adrenal enzyme inhibitors (eg, metyrapone or mitotane) may be used with ectopic ACTH-secreting tumors that cannot be totally removed; monitor closely for inadequate adrenal function and side effects
  • If Cushing’s syndrome results from exogenous corticosteroids, taper the drug to the minimum level or use alternate day therapy to treat the underlying disease.

NURSING PROCESS: The Patient with Cushing’s Syndrome


  • Focus on the effects on the body of high concentrations of adrenal cortex hormones
  • Assess patient’s level of activity and ability to carry out routine and self-care activities
  • Observe skin trauma, infection, breakdown, bruising and edema
  • Note changes in appearance and patient’s response to these changes, family is good source of information about patient’s emotional status and changes in appearance
  • Assess patient’s mental function. including mood, response to questions, depression, and awareness of environment


Nursing Diagnoses

  • Risk for injury related to weakness
  • Risk for infection related to altered protein metabolism and inflammatory response
  • Self-care deficits related to weakness, fatigue, muscle wasting, and altered sleep patterns
  • Impaired skin integrity related to edema, impaired healing, and thin and fragile skin
  • Disturbed body image related to altered appearance, impaired sexual functioning, and decreased activity level
  • Disturbed thought processes related to mood swings, irritability, and depression

Collaborative Problems/Potential Complications

  • Addisonian crisis
  • Adverse effects of adrenocortical activity

Planning and Goals

Major goals include decreased risk for injury, decreased risk for infection, increased ability to carry out self-care activities, impaired skin integrity, improved body image, improved mental function, and absence of complications.

Nursing Interventions

Decreasing Risk for Injury

  • Provide a protective environment to prevent falls, fractures, and other injuries to bones and soft tissues
  • Assist the patient who is weak in ambulating to prevent falls or colliding into furniture
  • Recommend foods high in protein, calcium, and vitamin D to minimize muscle wasting and osteoporosis; refer to dietitian for assistance

Decreasing Risk for Infection

  • Avoid unnecessary exposure to people with infections
  • Assess frequently for subtle signs of infections (corticosteroids mask signs of inflammation and infection)

Promoting Skin Care

  • Use meticulous skin care to avoid traumatizing fragile skin
  • Avoid adhesive tapes, which can tear and irritate the skin
  • Assess skin and bony prominences frequently
  • Encourage and assist patient to change positions ffrequently

Improving Body Image

  • Discuss the impact that changes have had on patient’s self-concept and relationships with others. Major physical changes will disappear  in time if the cause of Cushing’s syndrome can be treated.
  • Weight gain and edema may be modified by a low-carbohydrate, low-sodium diet; a high in protein intake can reduce some bothersome symptoms

Improving Thought Processes

  • Explain to patient and family the cause of emotional instability and help them cope with mood swings, irritability, and depression
  • Report any psychotic behavior
  • Encourage patient and family members to verbalize feelings

Encouraging Rest and Activity

  • Encourage moderate activity to prevent complications of immobility and promote self-esteem
  • Plan rest periods throughout the day and promote a relaxing, quiet environment for rest and sleep

Preparing Patient for Surgery

  • Adrenal hypofunction ans addisonians crisis: monitor for hypotension; rapid, weak pulse, rapid respiratory rate; pallor; and extreme weakness. Note factors that may have led to crisis (eg, stress, trauma, surgery).
  • Administer intravenous fluids and electrolytes  and corticosteroids before, during and after surgery or treatment as indicated.
  • Monitor for circulatory collapse and shock present in addisonian crisis; treat promptly.
  • Assess fluid and electrolyte status by monitoring laboratory values and daily weight.
  • Monitor blood glucose level, and report elevations to physician.



Joyce Young Johnson Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition

Lippincott Wiliams &Wilkins pp; 286-291