CARE FOR THE CLIENTS WITH DIABETES MELLITUS

(CLINICAL MANIFESTATION, ASSESSMENT & DIAGNOSTIC FINDINGS,

OVERALL MANAGEMENT OF DIABETES AND NURSING MANAGEMENT)

A. CLINICAL
Classic clinical manifestations of all types of diabetes include the “three Ps”:
 Polyuria
 Polydypsia
 Polyphagia

Other symptoms include:

 Fatigue and weakness

 Dry skin
 Sudden vision changes
 Tingling or numbness in hands or feet
 Skin lesions or wounds that are slow to heal and recurrent infections.
 Type 1 diabetes may be associated with sudden weight loss or nausea, vomiting,
abdominal pains if DKA has developed.

B. ASSESSMENT AND DIAGNOSTIC

CRITERIA FOR THE DIAGNOSIS OF DIABETES

American Diabetes Association (ADA, 2004)-Diagnostic criteria for Diabetes

Mellitus

1. Symptoms of diabetes plus casual plasma glucose concentration equal to or

greater than 200 mg/dL (11.1 mmol/L). Casual is defines as any time of day
without regard to time since last meal. The classic symptoms of diabetes
include polyuria, polydypsia, polyphagia and unexplained weight loss.
or
2. Fasting Plasma Glucose (FPG) or Fasting Blood Sugar (FBS) greater than or
equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for
atleast 8 hours.
or
3. Two-hour postload glucose equal to or greater than 200 mg/dL (11.1
mmol/dL) during an oral glucose tolerance test. The test should be performed
 as described by the World Health Organization, using a glucose load
containing the equivalent of 75 g anhydrous glucose dissolved in water.
In the absence of unequivocal hyperglycemia with acute metabolic
decompensation, these criteria should be confirmed by repeat testing on a
different day. The third measure is not recommended for routine clinical use.

 ABNORMAL LABORATORY VALUE FOR GLUCOSE

 Fasting Plasma Glucose (FPG) or Fasting Blood Sugar(FBS)
 126 mg/dL (7.0 mmol/L) above
 Random Plasma Glucose (RPG) or Random Blood Sugar (RBS)
 200 mg/dL (1.1 mmol/L) above
 NORMAL LABORATORY VALUE FOR GLUCOSE
 Glucose, Fasting: 70-110 mg/Dl
 Glucose, monitoring: 60-110 mg/dL
 Glucose, 2-hr postprandial: < 140 mg/dL

ASSESSING THE PATIENT WITH DIABETES

 HISTORY

 Symptoms related to the diagnosis of diabetes.

- Symptoms of hyperglycemia
- Symptoms of hypoglycaemia
Frequency, timing, severity, and resolution
 Results of blood glucose monitoring
 Status, symptoms, and management of chronic complications of diabetes:
- Eye; kidney; nerve; genitourinary and sexual, bladder, and gastrointestinal
- Cardiac; peripheral vascular; foot complications associated with diabetes
 Adherence to / ability to follow prescribed dietary management plan
 Adherence to prescribed exercise regimen
 Adherence to / ability to follow prescribed pharmacologic treatment ( insulin or
oral antidiabetic agents)
 Use of tobacco, alcohol, and prescribed and over-the-counter medications/ drugs
 Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes
treatment
 Effects of diabetes or its complications on functional status (eg, mobility, vision).

 PHYSICAL EXAMINATION
 Blood pressure (sitting and standing to detect orthostatic changes)
 Body mass index (height and weigth)
 Fundoscopic examination and visual acuity
 Foot examination (lesions, signs of infection, pulses)
  Skin examination (lesions and insulin-injection sites)
 Neurologic examination
- Vibratory and sensory examination using monofilament
- Deep tendon reflexes
- Oral examination

 LABORATORY EXAMINATION
 HgbA1c (AIC)
 Fasting lipid profile
 Test for microalbuminuria
 Serum creatinine level
 Urinalysis
 Electrocardiogram

 NEED FOR REFERRALS

 Ophthalmology
 Podiatry
 Dietitian
 Diabetes educator
 Others if indicated

C. OVERALL MANAGEMENT OF DIABETES

The therapeutic goal for diabetes management is to achieve normal blood glucose
levels (euglycemia) without hypoglycaemia while maintaining a high quality of life.
Five components in Diabetes management:
1) Nutritional therapy
2) Exercise
3) Monitoring
4) Pharmacologic therapy
5) Education

Treatment varies because of the changes in lifestyle and physical and emotional
status as well as advances in treatment methods. Therefore, Diabetes management
involves constant assessment and modification of the treatment plan by health
professionals and daily adjustments in therapy by the patient. Although the health
care team directs the treatment, it is the individual patient who must manage the
complex therapeutic regimen. For this reason, patient and family education is an
essential component of diabetes treatment and is as important as all other components
of the regimen.

1.) NUTRITIONAL THERAPY

 Nutritional management of diabetes includes the following goals (ADA, 2004):
 Providing all the essential food constituents (eg. Vitamins, minerals)
necessary for optimal nutrition
 Meeting energy needs
 Achieving and maintaining a reasonable weight
 Preventing wide daily fluctuations in blood glucose levels, with blood
glucose levels as close to normal as is safe and practical to prevent or
reduce the risk for complications
 Decreasing serum lipid levels, if elevated, to reduce the risk for
macrovascular disease.

MEAL PLANNING AND RELATED TEACHING

 CALORIC REQUIREMENTS
 Priority for a young patient with type 1 diabetes should be a diet with
enough calories to maintain normal growth and development.
 The goal with these patients initially may be to provide a higher-calorie
diet to regain lost weight.

 CALORIC DISTRIBUTION
 A meal plan for diabetes also focuses on the percentages of calories that
come from carbohydrates, proteins, and fats.

 CARBOHYDRATES
 Carbohydrate counting is another nutritional tool used for blood glucose
management, because carbohydrates are the main nutrients in food that
influence blood glucose level.
 Once digested, 100% of carbohydrates are converted to glucose.

 FATS
The recommendations regarding fat content of the diabetic diet include;
 Reducing the total percentage of calories from fat sources less than 30% of
total calories and limiting the amount of saturated fats to 10% of total
calories.
 Limit the total intake of dietary cholesterol to less than 300mg/day.
 This approach may help to reduce risk factors such as increase serum
cholesterol levels, which are associated with the development of coronary
artery disease, the leading cause of death and disability among people with
diabetes.
 Meal plan may include the use of some non-animal sources of protein
intake (eg, legumes, whole grains).
  FIBER
There are two types of dietary fibers; soluble and insoluble.
 Soluble fiber—in foods such as legumes, oats, and some fruits- plays
more of a role in lowering blood glucose and lipid levels.
 Insoluble fiber—is found in whole-grain breads and cereals and in some
vegestables. This type of fiber plays more of a role in increasing stool bulk
and preventing constipation.

OTHER DIETARY CONCERNS

 ALCOHOL CONSUMPTION
 A major danger of alcohol consumption by the patient with diabetes is
hypoglycemia.
 Excessive alcohol intake may impair the patient’s ability to recognize and
treat hypoglycemia or to follow a prescribed meal plan to prevent
hypoglycemia.
 Alcohol consumption may lead to excessive weight gain (from the high
caloric content of alcohol), hyperlipidemia, and elevated glucose levels
(especially with mixed drinks and liqueurs).

 SWEETENERS
Moderation in the amount of sweetener used is encouraged, to avoid potential
adverse effects. There are two main types of sweeteners: nutritive and non-
nutritive.

 Nutritive sweeteners contain calories (Fructose, sorbitol, and xylitol).

They provide calories in amounts similar to those in sucrose (table sugar).
They cause less elevation in blood sugar levels than sucrose does and are
often used in “sugar-free” foods.
 Non- nutritive sweeteners have few or no calories. They are used in food
products and are also available for table use. They produce minimal or no
elevation in blood glucose levels, have been approved by the U.S. FDA as
safe for people with diabetes.

 MISLEADING FOOD LABELS

 Foods labelled “sugarless” or “sugar-free” may still provide calories equal
those of the equivalent sugar-containing products if they are made with
nutritive sweeteners.
  Foods labelled “diatetic” are not necessarily reduce-calorie foods. May
still contain significant amounts of sugar or fat.

2.) EXERCISE

 GENERAL PRECAUTIONS FOR EXERCISE IN PEOPLE WITH DIABETES

 Use proper footwear and, if appropriate, other protective equipment.

 Avoid exercise in extreme heat or cold.
 Inspect feet daily after exercise.
 Avoid exercise during periods of poor metabolic control.

GERONTOLOGIC CONSIDERATIONS

Age-Related Changes That May Affect Diabetes and Its Management

 SENSORY CHANGES
 Decreased vision
 Decreased smell
 Taste changes
 Decreased proprioception
 Diminished thirst
 GASTROINTESTINAL CHANGES
 Dental problems
 Appetite changes
 Delayed gastric emptying
 Decrease bowel motility
 ACTIVITY/EXERCISE PATTERN CHANGES
 More sedentary
 RENAL FUNCTION CHANGES
 Decreased function
 Decreased drug clearance
 AFFECTIVE/COGNITIVE CHANGES
 Medications/meals omitted or taken erratically
  SOCIOECONOMIC FACTORS
 Fad diets
 Loneliness/living alone
 Lack of money/lack of support system
 CHRONIC DISEASES
 Hypertension
 Arthritis
 Neoplasms
 Acute/chronic infections
 POTENTIAL DRUG INTERACTIONS
 Use of another person’s medications
 Consulting multiple physicians for different illnesses
 Alcohol use/abuse

3.) MONITORING GLUCOSE LEVELS AND KETONES

 Self-Monitoring of Blood Glucose (SMBG)

 Blood glucose monitoring is a cornerstone of diabetes management.
 This allows detection and prevention of hypoglycemia and hyperglycemia and plays a
crucial role in normalizing blood glucose levels, which in turn may reduce the risk of
long-term diabetic complications.
 Most involve obtaining a drop of blood from the fingertip, applying the blood to a special
reagent strip, and allowing the blood to stay on the strip for the amount of time specified
by the manufacturer (usually 5 to 30 sec.).The meter gives a digital readout of the blood
glucose value.
 Some meters are biosensors that can use blood obtained from alternative test sites, such
as the forearm. They lancing device that is useful for patients who have painful fingertips
or experience pain with fingersticks.

ADVANTAGES AND DISADVANTAGES OF SMBG SYSTEMS

 The use of meters to monitor blood glucose is recommended, because meters have
become much less expensive and less dependent on technique, making the results more
accurate.
 Some common sources of error include the following:
o Improper application of blood (eg, drop too small)
o Damage to the reagent strips caused by heat or humidity; use of outdated
strips
o Improper meter cleaning and maintenance (eg, allowing dust or blood to
accumulate on the optic window). This is not an issue in the biosensor
type of meter.
  Nurses play an important role in providing initial teaching about SMBG techniques.
 Evaluating the techniques of patients who are experienced in self-monitoring.
 Patients should be discouraged from purchasing SMBG products from stores or catalogs
that do not provide direct education.
 Every 6 to 12 months, patients should conduct a comparison of their meter result with a
simultaneous laboratory-measured blood glucose level in their physician’s office.
 The accuracy of the meter and strips should also be assessed with control solutions
specific to that meter whenever a new vial of strips is used and whenever the validity of
the reading is in doubt.

CANDIDATES FOR SMBG

 For everyone with diabetes.

 For diabetes management during pregnancy.
 It is also recommended for patients with the following conditions:
 Unstable diabetes (severe swings from very high to very low blood glucose levels
within a 24-hour day)
 A tendency to develop severe ketosis or hypoglycemia
 Hypoglycemia without warning symptoms

FREQUENCY OF SMBG

 For most patient who require insulin, SMBG is recommended two to four times daily
(usually before meals and at bedtime).
 Patients not receiving insulin may be instructed to assist their blood glucose levels at least
two or three times per week, including a 2-hour postprandial test.

CONTINUOUS GLUCOSE MONITORING SYSTEM (CGMS)

 A sensor attached to an infusion set, which is similar to an insulin pump infusion set, is
inserted subcutaneously in the abdomen and connected to the device worn on a belt. After
72 hours, the data from the device are downloaded, and blood glucose readings are
analyzed.
 CGMS cannot be used for making decision about specific insulin doses, but it can be
used to determine whether treatment is adequate over a 24-hour period.

GLYCATED HEMOGLOBIN

 Glycated haemoglobin (also reffered to as glycosylated haemoglobin, HgbA1c, or AIC)

is a blood test that reflects average blood glucose levels over a period of approximately 2
to 3 months.

URINE GLUCOSE TESTING

 No longer used for monitoring diabetes on a daily basis.

 TESTING FOR KETONES

 Ketones (or ketone bodies) are by products of fat breakdown, and they accumulate in the
blood and urine.
 Urine testing is the most common method used for self-testing of ketone bodies by
patients. A meter that enables testing of blood for ketones is available.
 Urine dipstick (Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the
strip turns purplish when ketones are present.
 Other strips are available for measuring both urine glucose and ketones (Keto-Diastix or
Chempstrip uGK). Large amounts of ketones may depress the color response of the
glucose test area.
 Urine ketone testing should be performed whenever patients with type 1 diabetes have
glycosuria or persistently elevated blood glucose levels
(more than 240mg/dL or 13.2 mmol/L for two testing periods in a row) and during the
illness, in pregnancy with pre-existing diabetes, and in gestational diabetes (ADA,
2004w)

4.) PHARMACOLOGIC THERAPY

INSULIN THERAPHY AND INSULIN PREPARATIONS

 In type 1 diabetes, exogenous insulin must be administered for life because the body
loses the ability to produce insulin.
 In type 2 diabetes, insulin may be necessary on a long-term basis to control glucose levels
if meal planning and oral agents are ineffective.
 Some patients in whom type 2 diabetes is usually controlled by meal planning alone or by
meal planning and an oral anti-diabetic agent may require insulin temporarily during
illness, infection, pregnancy, surgery, or some other stressful event.
 A number of insulin preparations are available. They vary according to three main
characteristics;
 Time course of action
 Species (source)
 Manufacturer

CATEGORIES OF INSULIN

TIME COURSE AGENT ONSET PEAK DURATION INDICATIONS

Rapid-acting Lispro (Humalog) 10-15 min 1 hr 2-4h Used for rapid reduction of glucose level, to treat
Aspart (Novolog) 5-15 min 40- 2-4h postprandial hyperglycemia, and/or to prevent
50min nocturnal hypoglycemia
Short-acting Regular (Humalog ½- 1 h 2-3 h 4-6h Usually administered 20-30 min before a meal;
R, Novolin R, may be taken alone or in combination with
Iletin II Regular) longer-acting insulin
Intermediate- NPH (neutral 2-4h 4-12h 16-20h Usually taken after food
acting protamine
Hagedorn)
(Humulin N, Iletin 3-4h 4-12h 16-20h
II Lente, Iletin II
 NPH, Novolin L
(Lente), Novolin N
(NPH)
Long-acting Ultralente (“UL”) 6-8h 12-16h 20-30h Used primarily to control fasting glucose level
Very long-acting Glargine (Lantus) 1h Continu 24h Used for basal dose
ous (no
peak)

SPECIES (SOURCE)

 In the past, all insulins were obtained from beef (cow) and pork (pig) pancreases.
“Human insulins” are now widely available. They are produced by recombinant DNA
technology and have largely replaced insulin from animal sources (ADA, 2004k). These
insulins are largely preferable to animal source insulins because they are not antigenic
and do not depend on sufficient animal sources.

INSULIN REGIMENS

 Insulin regimens vary from one to four injections per day. Usually there is combination
of a short-acting insulin and a longer-acting insulin.

There are two general approaches to insulin therapy: conventional and intensive

 Conventional Regimen
 With this type of simplified regimen (eg, one or more injections of a mixture of
short- and intermediate-acting insulins per day), the patient should not vary meal
patterns and activity levels.
 The simplified regimen would be appropriate for the terminally ill, the frail
elderly with limited self-care abilities, or patients who are completely unwilling or
unable to engage in the self-management activities that are part of a more
complex insulin regimen.
 Intensive Regimen
 The second approach is to use a more complex insulin regimen to achieve as
much control over blood glucose levels as is safe and practical.

COMPLICATIONS OF INSULIN THERAPY

 LOCAL ALLERGIC REACTIONS

 A local allergic reaction (redness, swelling, tenderness, and induration or a 2- to
4-cm wheal) may appear at the injection site 1 to 2 hours after insulin
administration.
 SYSTEMIC ALLERGIC REACTIONS
  Systemic allergic reactions to insulin are rare. When they do occur, there is an
immediate local skin reaction that gradually spreads into generalized urticaria
(hives).
 INSULIN LIPODYSTROPHY
 Lipodystrophy refers to a localized reaction, in the form of either lipoatrophy or
lipohypertrophy, occurring at the site of insulin injections.

RESISTANCE TO INJECTED INSULIN

 Most patients have some degree of insulin resistance at one time or another. This may
occur for various reasons, the most common being obesity, which can be overcome by
weight loss.
 Clinical insulin resistance has been defined as a daily insulin requirement of 200 units or
more.

ALTERNATIVE METHODS OF INSULIN DELIVERY

 INSULINS PENS
 Insulin pens use small (150- to 300- unit) prefilled insulin cartridges that are loaded
into a penlike holder.
 These devices are most useful for patients who need to inject only one type of insulin
at a time (eg, premeal rapid acting insulin three times a day and bedtime NPH insulin)
or who can use the premixed insulins.
 They are also useful for patients with impaired manual dexterity, vision, or cognitive
function that makes the use of traditional syringes difficult.
 JET INJECTIONS
 As an alternative to needle injections, jet injection devices deliver insulin through
the skin under pressure in an extremely fine stream. These devices are more
expensive and require thorough training and supervision when first used.
 INSULIN PUMPS
 Continuous subcutaneous insulin infusion involves the use of small, externally
worn devices that closely mimic the functioning of the normal pancreas (ADA,
2004c).
 Insulin pumps contain a 3-mL syringe attached to a long (24-to 42-in), thin,
narrow-lumen tube with a needle or Teflon catheter attached to the end.
 IMPLANTABLE AND INHALANT INSULIN DELIVERY
 Clinical trials with these devices are continuing. There is research into the
development of implantable devices that both measure the blood glucose level
and deliver insulin as needed.
 TRANSPLANTATION OF PANCREATIC CELLS
  Implantation of insulin- producing pancreatic islet cells is another approach under
investigation (ADA, 2004m). This latter approach involves a less extensive
surgical procedure and a potentially lower incidence of immunogenic problems.
 Independence from exogenous insulin has been limited to 2 years after
transplantation of islet cells.

ORAL ANTI-DIABETIC AGENTS

Oral anti-diabetic agents may be effective for patients who have type 2 diabetes that
cannot be treated effectively with MNT and exercise alone.

 SULFONYLUREAS
 First-Generation Sulfonylureas
 Acetohexamide (Dymelor)
 Chlorpropamide (Diabinese)
 Tolazamide (Tolinase)
 Tolbutamide (Orinase)
 Second-Generation Sulfonylureas
 Glipizide (Glucatrol, Glucatrol XL)
 Glyburide (Micronase, Glynase, Dia-Beta)
 Glimepiride (Amaryl)
 Non-sulfonylurea Insulin Secretagogues
 Repaglinide (Prandin)
 Naglitinide (Starlix)
 BIGUANIDES
 Metformin (Glucophase, Glucophage XL, Fortamet)
 Metformin with glyburide (Glucovance)
 ALPHA-GLUCOSIDASE INHIBITORS
 Acarbose (Precose)
 Miglitol (Glyset)
 THIAZOLIDINEDIONES (OR GLITAZONES)
 Pioglitazone (Actos)
 Rosiglitazone (Avandia)
 OTHER PHARMACOLOGIC THERAPY
 Pramlintide (Symlin)
 Exanatide (Byetta)

D. NURSING MANAGEMENT

PATIENT EDUCATION

 ORGANIZING INFORMATION
  One approach is to organize education using the seven tips for managing diabetes
identified and developed by the AADE (2004):
1) Healthy eating
2) Being active
3) Monitoring
4) Taking medicines
5) Problem solving
6) Reducing risks
7) Healthy coping

Another general approach is to organize information and skills into two main types:
basic, initial, or “survival” skills and information, and in-depth (advanced) or continuing
education.

TEACHING SURVIVAL SKILLS

An outline of survival information includes the following:

1. Simple pathophysiology
a. Basic definition of diabetes (having a high blood glucose level)
b. Normal blood glucose ranges and target blood glucose levels
c. Effect of insulin and exercise (decrease glucose)
d. Effect of food and stress, including illness and infections (increase glucose)
e. Basic treatment approaches
2. Treatment modalities
a. Administration of insulin and oral anti-diabetes medications
b. Meal planning (food groups, timing of meals)
c. Monitoring of blood glucose and urine ketones
3. Recognition, treatment, and prevention of acute complications
a. Hypoglycemia
b. Hyperglycemia
4. Pragmatic information
a. Where to buy and store insulin, syringes, and glucose monitoring supplies
b. When and how to contact the physician

PLANNING IN-DEPTH AND CONTINUING EDUCATION

Preventive measures include:

 Foot care
 Eye care
 General hygiene (eg, skin care, oral hygiene)
 Risk factor management (eg, control of blood pressure and blood lipids levels,
normalizing blood glucose levels)
 Assessing readiness to learn
 Determining teaching methods
IMPLEMENTING THE PLAN

 Teaching Experienced Patients

 Teaching Patients to Self-administer Insulin
 Storing Insulin
o Extremes of temperature should be avoided; insulin should not be allowed
to freeze and should not be kept in direct sunlight or in a hot car.
o The insulin vial in used should be kept at room temperature.
o Cloudy insulins should be thoroughly mixed by gently inverting the vial or
rolling it between hands before drawing the solution into a syringe or a
pen.
o Bottles or intermediate-acting insulin should also be inspected for
flocculation, which is a frosted, whitish coating inside the bottle. If a
frosted, adherent coating is present, some of the insulin is bound, and it
should not be used.
 Selecting Syringes
Syringe must be matched with the insulin concentration (eg, U-100).
Currently, three sizes of U-100 insulin syringes are available:
o 1-mL syringes that hold 100 units
o 0.5-mL syringes that hold 50 units
o 0.3-mL syringes that hold 30 units
 Preparing the Injection: Mixing Insulins
o When rapid- or short-acting insulins are to be given simultaneously with
longer-acting insulins, they are usually mixed together in the same
syringe; the longer-acting insulins must be mixed thoroughly before use.
The most important issue is that patients be consistent in how they prepare
their insulin injections from day to day.
 Withdrawing Insulin
 Selecting and Rotating the Injection Site
o Four main areas for injection are the abdomen, upper arms (posterior
surface), thighs (anterior surface), and hips.
o The speed of absorption is greatest in the abdomen and decreases
progressively in the arm, thigh, and hip, respectively.
o Systematic rotation of injection sites within an anatomic area is
recommended to prevent localized changes in fatty tissue (lipodystrophy).
o In addition, to promote consistency in insulin absorption.
 Preparing the Skin
o Use of alcohol to cleanse the skin is not recommended.

 Inserting the Needle

 o The correct technique is based on the need for the insulin to be injected
into the subcutaneous tissue.
o Injection that is too deep (eg. Intramuscular) or too shallow may affect the
rate of absorption of the insulin.
o Aspiration is generally not recommended with self- injection of insulin.
 Disposing of Syringes and Needles
 Promoting Home and Community-Based Care
o Teaching Patient Self-Care
o Continuing Care

REFERENCES:
Medical-Surgical Nursing Brunner & Suddhart (11th edition)
Medical-Surgical Nursing: Concepts and Clinical Application (1st Edition)
(Jose Quiambao-Udan, RN,MAN)

PREPARED BY:
Angel Ann G. Talento
BSN-III PURE

SUBMITTED TO:
Mrs. Adelfa Candida Villaluz RN