Module 6: Introduction to Diabetes Mellitus

Introduction (I) - Part A

Overview
 Diabetes mellitus is a multisystem disease characterized by abnormal insulin secretion,
impaired insulin usage, or both, and is a contributing factor in the deaths of more than
40,000 Canadians each year (Dickinson, 2019). Module 6 is an introduction to type 1 and
type 2 diabetes, related pharmacotherapy, and nursing management of this serious health
challenge. This topic will be further explored in the Complex Health Challenges course.
Learning Outcomes
 Review the normal actions and functions of the pancreas.
 Review the pathophysiology and clinical manifestations of diabetes.
 Review the differences between type 1 and type 2 diabetes.
 State the potential long-term consequences of diabetes.
 Describe the collaborative care required for a patient with diabetes.
 Describe the role of nutrition and exercise in the management of diabetes.
 Describe the role of the registered nurse when caring for a patient with newly
diagnosed diabetes.
 Formulate a plan of nursing care, using the nursing process, for persons
experiencing diabetes.
 Describe the mechanism of action, indications, contraindications, cautions, drug
interactions, and adverse effects of insulin and oral antihyperglycemic drugs.
Required Readings
Lewis
 Chapter 52 – Diabetes Mellitus, pgs. 1287-1310
Jarvis
 No assigned readings
Lilley
 Chapter 33 – Antidiabetic Drugs
Other
Registered Nurses’ Association of Ontario (2013). Assessment and management of foot ulcers for
people with diabetes (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario.
Retrieved
from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Management_of_Foot_Ulcers_for_
People_with_Diabetes_Second_Edition1.pdf

Concepts and Theory (C)- Part A

The module ‘Concepts and Theory Worksheet’ outlines the main concepts and important theory
for each module. The worksheet below can be filled in when completing the required readings
and saved as a study resource for the NSGD 2117 course, future clinical courses, and when
preparing to write the NCLEX-RN exam. There are no requirements for learners to submit the
module concepts and theory worksheet.

Concepts & Theory Worksheet

1. Review the functions and actions of the pancreas (see Lilley text).
Endocrine functions: The pancreas is a large, elongated organ located behind the stomach. It
functions as an exocrine gland (secreting digestive enzymes through the pancreatic duct) and a
ductless endocrine gland (secreting hormones directly into the bloodstream).

Insulin and glucagon are the two main hormones produced by the pancreas. Both hormones play
an important role in the regulation of glucose homeostasis, specifically the mobilization, use, and
storage of glucose by the body

Metabolic functions:
 Carbohydrate metabolism: Diabetes is primarily a disorder of carbohydrate metabolism
that involves either a deficiency of insulin, a resistance of tissue (e.g., muscle, liver) to
insulin, or both

 Fat metabolism:

2. Complete the chart outlining the pathophysiology and symptoms for type 1 and type 2
diabetes (use Lilley and Lewis texts).

Type 1 Diabetes Type 2 Diabetes

Pathophysiology Type 1 Diabetes (T1D) is an Type 2 Diabetes Mellitus (T2DM) is

autoimmune condition characterized by insulin resistance and a
characterized by the destruction progressive decline in pancreatic beta-cell
of insulin-producing beta cells function. In the early stages of T2DM, target
in the pancreas. This tissues such as muscle, fat, and the liver
autoimmune attack is primarily become resistant to the effects of insulin, a
mediated by T-cells and results hormone that facilitates glucose uptake into
in an absolute deficiency of cells. As a result, glucose remains in the
insulin, a hormone critical for bloodstream, leading to hyperglycemia. The
glucose uptake by cells. The pancreas initially compensates for insulin
exact cause of this autoimmune resistance by producing more insulin.
response is not entirely However, over time, the beta cells become
understood but is believed to dysfunctional and fail to produce enough
involve a combination of insulin to overcome the resistance,
genetic predisposition and exacerbating hyperglycemia.
environmental factors such as
viral infections. Without
sufficient insulin, glucose
accumulates in the bloodstream,
leading to hyperglycemia.

Diagnostic The diagnostic criteria for The diagnostic criteria for Type 2 Diabetes
Criteria diabetes mellitus, including Mellitus (T2DM) are based on specific blood
(see pg. 624 in Type 1 Diabetes (T1D), are glucose levels and are aimed at identifying
Lilley text) established to ensure accurate individuals at risk for diabetes-related
 diagnosis and timely complications. Diagnosis can be made using
management. A diagnosis can several tests. The fasting plasma glucose
be made based on several tests. (FPG) test measures blood glucose after an
The fasting plasma glucose overnight fast, with a level of 126 mg/dL
(FPG) test is one criterion, with (7.0 mmol/L) or higher indicating diabetes.
a result of 126 mg/dL (7.0 Another test is the oral glucose tolerance test
mmol/L) or higher indicating (OGTT), which assesses blood glucose two
diabetes. Another criterion is the hours after consuming a 75-gram glucose
oral glucose tolerance test drink, with a result of 200 mg/dL (11.1
(OGTT), where a 2-hour plasma mmol/L) or higher confirming diabetes. A
glucose level of 200 mg/dL random plasma glucose test, taken at any
(11.1 mmol/L) or higher after a time regardless of meal timing, with a level
75-gram glucose load confirms of 200 mg/dL (11.1 mmol/L) or higher,
the diagnosis. Additionally, a along with classic symptoms of
random plasma glucose test hyperglycemia, also confirms the diagnosis.
with a result of 200 mg/dL (11.1 Additionally, the hemoglobin A1c (HbA1c)
mmol/L) or higher, in the test, which reflects average blood glucose
presence of classic symptoms of levels over the past two to three months, is
hyperglycemia or used, with a value of 6.5% (48 mmol/mol) or
hyperglycemic crisis, is higher indicating diabetes. These criteria
diagnostic of diabetes. The help in early detection and management,
hemoglobin A1c (HbA1c) test, preventing long-term complications
which reflects average blood associated with T2DM.
glucose levels over the past two
to three months, is also used,
with a value of 6.5% (48
mmol/mol) or higher indicative
of diabetes. These criteria help
differentiate between normal
glucose regulation, prediabetes,
and diabetes, guiding
appropriate treatment and
management strategies.

Clinical Clinical manifestations of Type The clinical manifestations of Type 2

Manifestations 1 Diabetes (T1D) typically Diabetes Mellitus (T2DM) often develop
present suddenly and can be gradually and can be subtle, making early
severe. The hallmark symptoms detection challenging. Common symptoms
include polyuria (frequent include polyuria (frequent urination),
urination), polydipsia (excessive polydipsia (excessive thirst), and polyphagia
thirst), and polyphagia (increased hunger). Despite increased
(increased hunger). These occur hunger, individuals may experience
due to the body's inability to unexplained weight loss due to the body's
utilize glucose for energy, inability to effectively use glucose for
 leading to elevated blood energy. Fatigue and weakness are also
glucose levels. Weight loss is prevalent as the cells are deprived of
another common symptom, as glucose. Other symptoms include blurred
the body begins to break down vision, which results from osmotic changes
fat and muscle for energy in the in the lens due to high blood glucose levels,
absence of insulin. Individuals and slow-healing sores or frequent
may also experience fatigue and infections, as elevated glucose levels impair
weakness due to the lack of immune function. T2DM can also lead to
usable glucose. Blurred vision darkened skin areas, usually in the armpits
can occur from osmotic changes and neck, known as acanthosis nigricans,
in the lens of the eye caused by which is associated with insulin resistance.
high blood glucose levels. If left As the disease progresses, complications
untreated, T1D can lead to such as neuropathy, retinopathy,
diabetic ketoacidosis (DKA), a nephropathy, and cardiovascular issues may
serious condition characterized arise. Early recognition and management of
by nausea, vomiting, abdominal these symptoms are crucial to prevent severe
pain, rapid breathing, and a complications and improve quality of life for
distinctive fruity odor on the individuals with T2DM.
breath due to the buildup of
ketones in the blood. Early
recognition and management of
these symptoms are crucial to
prevent acute and long-term
complications associated with
T1D.

3. Identify the major long-term consequences of diabetes.

a) Microvascular: The major long-term microvascular consequences of diabetes primarily affect
the small blood vessels and include diabetic retinopathy, nephropathy, and neuropathy. Diabetic
retinopathy is a leading cause of blindness in adults and occurs due to damage to the tiny blood
vessels in the retina, leading to vision impairment and potential blindness if untreated. Diabetic
nephropathy, characterized by damage to the kidney's delicate filtering systems, can progress to
chronic kidney disease and end-stage renal failure, necessitating dialysis or kidney
transplantation. Diabetic neuropathy affects the nerves, particularly in the extremities, leading to
symptoms such as pain, tingling, and loss of sensation. This increases the risk of foot ulcers and
infections, which can result in amputations if not properly managed. These microvascular
complications are primarily driven by chronic hyperglycemia, which causes structural and
functional abnormalities in the small blood vessels, underscoring the importance of effective
blood glucose control to mitigate these long-term risks.

b) Macrovascular: The major long-term macrovascular consequences of diabetes involve the

large blood vessels and significantly increase the risk of cardiovascular diseases. These include
coronary artery disease (CAD), which can lead to heart attacks; cerebrovascular disease,
resulting in strokes; and peripheral artery disease (PAD), which causes reduced blood flow to the
limbs. The underlying mechanism involves chronic hyperglycemia, which promotes
atherosclerosis— the buildup of plaques in the arterial walls. This process is accelerated in
individuals with diabetes due to factors like hypertension, dyslipidemia (abnormal blood lipid
levels), and inflammation. Over time, these plaques can rupture or cause blockages, leading to
ischemic events such as myocardial infarction or stroke. Additionally, PAD can result in pain,
ulcers, and potential limb amputations due to poor circulation. Managing blood glucose levels,
blood pressure, and cholesterol, alongside lifestyle changes like a healthy diet, regular exercise,
and smoking cessation, is crucial in reducing the risk of these macrovascular complications in
individuals with diabetes.

4. Complete the chart outlining nutritional therapy for clients with diabetes (see Table 52-8
on pg. 1301 in Lewis text):

Factor Type 1 Diabetes Type 2 Diabetes

Total calories Increase in caloric intake Reduction in caloric intake desirable for
possibly necessary to overweight or obese patient
achieve desirable body
weight and restore body
tissues

Effect of diet Diet and insulin necessary Diet alone possibly sufficient for glucose
for glucose control control

Distribution of Equal distribution of Equal distribution recommended; low-fat diet

calories carbohydrates through desirable; consistency of carbohydrate at
meals or adjustment of meals desirable
carbohydrates for insulin
activity

Consistency in Necessary for glucose Desirable for weight reduction and

daily intake control moderation of blood glucose levels

Uniform timing of Crucial for NPH insulin Desirable but not essential, unless using
meals programs; flexibility with insulin or sulphonylureas
multidose rapid-acting
insulin

Intermeal and Frequently necessary Is based on patient's eating habits and

bedtime preferences; may be necessary if using insulin
snacks or sulphonylureas
 Nutritional Carbohydrates 20 g/hr for May be necessary if patient's blood glucose
supplement for moderate physical activities levels are controlled on sulphonylureas or
exercise programs insulin

5. Formulate a plan of nursing care for a simulated client with diabetes, using the
information from the readings and posted project assignment.

Care plan: Diabetes Description and Rationale

Pathophysiology  Diabetes mellitus (DM) is a chronic metabolic disorder

characterized by elevated blood glucose levels due to insufficient
insulin production or impaired insulin utilization.
 Types of diabetes include:
o Type 1 diabetes: Autoimmune destruction of pancreatic
beta cells, leading to absolute insulin deficiency.
o Type 2 diabetes: Insulin resistance and relative insulin
deficiency.
o Gestational diabetes: Occurs during pregnancy.
 Chronic hyperglycemia affects multiple organs and systems,
leading to complications.

Nursing assessments  Risk Factors Assessment:

o Identify risk factors (e.g., family history, obesity,
sedentary lifestyle).
 Physical Assessment:
o Monitor blood glucose levels.
o Assess for signs of complications (e.g., neuropathy,
retinopathy, nephropathy).

Nursing diagnoses  Deficient Knowledge regarding diabetes management.

 Risk for Unstable Blood Glucose due to inadequate control.
 Impaired Skin Integrity related to neuropathy.
 Risk for Infection due to compromised immune function.

Planning and goals  Achieve and maintain optimal blood glucose levels.
 Educate the patient about self-management.
 Prevent complications.
 Promote overall well-being.

Nursing interventions  Patient Education:

 o Teach about blood glucose monitoring, medication
administration, and lifestyle modifications.
o Address psychosocial aspects of living with diabetes.
 Blood Glucose Control:
o Administer insulin or oral antidiabetic agents as
prescribed.
o Monitor blood glucose levels regularly.
 Foot Care:
o Inspect feet daily.
o Educate on proper foot hygiene and footwear.
 Nutritional Counseling:
o Collaborate with a dietitian to create a personalized meal
plan.
o Emphasize portion control and balanced nutrition.
 Exercise Promotion:
o Encourage regular physical activity.
o Monitor blood glucose response to exercise.
 Infection Prevention:
o Educate about wound care and hygiene.
o Monitor for signs of infection.

Teaching self-care/  Provide resources for support groups and diabetes education.
Continuing care  Discuss long-term management and follow-up appointments.

Evaluation  Regularly assess the patient’s progress toward blood glucose

goals, lifestyle changes, and overall health.

6. Complete the following chart on insulin therapy (Dickinson, 2019; Lilley, 2017).

Categories of Insulin

Nursing
Classification Examples Onset Peak Duration Considerations

Patients must eat a

meal 15 min after
Insulin injection to prevent
Rapid- acting lispro (Humalog 10-15 1-2 3.5-4.75 profound hypoglycemia
analogue ) min hrs hrs (Lilley, 2017).
 Short acting

Intermediate
acting

Extended
long-acting
analogue

Premixed

7. Complete the following chart on oral antidiabetic therapy (Dickinson, 2019; Lilley,
2017).

Type Mechanism of Adverse Effects Nursing Considerations

Action

Sulphonylureas Stimulate release Weight gain, Monitor blood glucose

of insulin from hypoglycemia Assess for hypoglycemia
beta cells; Administer medication 30 mins
decrease before meals
glycogenolysis Encourage daily exercise
and Assess renal function
gluconeogenesis Limit alcohol consumption
; glimepiride Monitor for allergic
may improve reactions/drug interactions
insensitivity in Regular follow ups with
tissues endocrinologist

Meglitinide Stimulates a Less weight gain, Monitor blood glucose

rapid and short- decreased incidence Administer 15-30 mins before
lived release of of hypoglycemia meals
insulin from the compared with Assess for hypoglycemia
pancreas glyburide Flexible dosing allows to skip
administration if skipped meal
Assess for drug interactions
Assess for renal function

Biguanide Inhibits hepatic Nausea, upset Monitor blood glucose

 glucose stomach, diarrhea; Assess for renal function
production; less weight gain than
increases sulphonylureas and
peripheral and does not cause
liver sensitivity hypoglycemia;
to insulin potential lactic
acidosis in renal or
hepatic impairment;
has to be held at the
time of or before
procedures and held
for 48 hr after
administration of IV
contrast media

α-Glucodisase Delays Flatulence,

inhibitors absorption of abdominal pain,
glucose and diarrhea
digestion of
CHO in small
intestine,
lowering after-
meal blood
glucose levels

Thiazolidinediones ↑ Glucose Edema, weight gain,

uptake in muscle heart failure; causes
and fat; inhibit ovulation in
hepatic glucose premenopausal
production women with PCOS;
not recommended
for patients with
heart failure

Dipeptidyl Enhance the Upper respiratory

Peptidase-4 incretin system, tract infection, sore
inhibitors stimulate release throat, headache,
of insulin from diarrhea
pancreatic beta
cells, and inhibit
hepatic glucose
production
8. Formulate a teaching plan for a patient newly diagnosed with diabetes. Include the
components and rationale outlined in the following chart:

Teaching Topic Main Points Rationale

to Include

Symptoms of
Diabetes

Medications (insulin
& oral antidiabetics)

Diet

Exercise

Alcohol intake

Self-Monitoring of
Blood Glucose

Personal Hygiene

Medical
Identification and
Travel

Apply (A)- Part B

Online Learning Activities:
The course instructor/ professor will provide the learning activities to apply and critically
analyze the module theory, concepts, and relevant best practice guidelines.

Reflect (R)- Part B

A. Self-reflection & self-care:
Complete the diabetes risk assessment on the Diabetes Canada website and reflect on strategies
you can incorporate into your life to mitigate your risk for developing
diabetes. https://canrisk.diabetes.ca/

B. Review the sample NCLEX-style questions:

1. Which is the most appropriate timing for the nurses’ administration of a rapid-acting insulin to
a hospitalized patient?
a) Give it 15 minutes before the patient begins eating a meal.
b) Give it ½ hour before a meal.
c) Give it 1 hour after a meal.
d) The timing of the insulin injection does not matter with a rapid-acting insulin.
2. Which statement is appropriate for the nurse to include in patient teaching regarding type 2
diabetes?
a) “Insulin injections are never used with type 2 diabetes.”
b) “You don’t need to measure your blood glucose levels because you are not taking insulin
injections.”
c) “A person with type 2 diabetes still has functioning β-cells in the pancreas.”
d) “Patients with type 2 diabetes usually have better control over their diabetes than those
with type 1.”
3. The home health nurse visits a client with a diagnosis of type 1 diabetes. The client relates a
history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last
24 hours. Which additional statement by the client indicates a need for further teaching?
a) “I need to stop my insulin.”
b) “I need to increase my fluid intake.”
c) “I need to monitory my blood glucose every 3 to 4 hours.”
d) “I need to call the health care provider because of these symptoms.”
4. The nurse is monitoring a client newly diagnosed with diabetes for signs of complications.
Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic
complications of diabetes if the blood glucose is not adequately managed?
a) Polyuria
b) Diaphoresis
c) Pedal edema
d) Decreased respiratory rate.
5. The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe.
Which action, if performed by the client, indicates the need for further teaching?
a) Withdraws the NPH insulin first.
b) Withdraws the regular insulin first.
c) Injects air into NPH insulin vial first.
d) Injects an amount of air equal to the desired dose of insulin into each vial.
6. The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes
who has been prescribed metformin. Which client statement indicates the need for further
teaching?
a) “It is okay if I skip meals now and then.”
b) “I need to constantly watch for signs of low blood sugar.”
 c) “I need to let my health care provider know if I get unusually tired.”
d) “I will be sure not to drink excessive amounts of alcohol while on this medication.”

Extend (E)- Part B

Ogston-Tuck, S. (2014). Subcutaneous injection technique: An evidence-based
approach. Nursing Standard, 29(3), 53-58. Retrieved
from https://rcni.com/sites/rcn_nspace/files/ns.29.3.53.e9183.pdf

Registered Nurses’ Association of Ontario. (2013). Assessment and management of foot ulcers
for people with diabetes (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario.
Retrieved
from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Management_of_Foot_Ulcers_for_Peop
le_with_Diabetes_Second_Edition1.pdf