Diabetes Mellitus/

Gestational Diabetes
 Definition
-A condition in which hormone made by the placenta prevents the
body from using insulin effectively glucose builds up in the blood
instead of being absorbed by the cells. Unlike the type 1 diabetes that
is caused by a lack of insulin gestational diabetes mellitus is a
hormone produced by pregnant women that can make insulin less
effective.
WHAT IS ENDOCRINE SYSTEM?
Endocrine system plays a vital role in orchestrating transportation of
chemicals across cell membranes, growth and development, metabolism,
fluid and electrolyte balance, acid-base balance, adaptation, and
reproduction (Norris,2019). This system involves in the release of
chemical transmitter substances known as hormones.

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 Insulin
A hormone secreted by islet cells of pancreas, is required to
facilitate the movement of glucose across cell membranes. Once inside
the cell, glucose is the primary metabolic fuel.

PATHOPHYSIOLOGY OF INSULIN
Insulin is a hormone secreted by beta cells, which are one of four types
of cells in the islets of Langerhans in the pancreas (Norris, 2019). Insulin
is an anabolic, or storage, hormone.

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 When a person eats a meal, insulin secretion increases and
moves glucose from the blood into muscle, liver, and fat cells.
In those cells, insulin has the following actions:
•Transports and metabolizes glucose for energy
•Stimulates storage of glucose in the liver and muscle (in the form of glycogen)
•Signals the liver to stop the release of glucose
• Enhances storage of dietary fat in adipose tissue
• Accelerates transport of amino acids (derived from dietary protein) into cells
•Inhibits the breakdown of stored glucose, protein, and fat

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CLINICAL MANIFESTATIONS
-Clinical manifestations depend on the patient’s level of hyperglycemia.
Classic clinical manifestations of diabetes include the “three Ps”: polyuria,
polydipsia, and polyphagia. Polyuria (increased urination) and polydipsia
(increased thirst) occur as a result of the excess loss of fluid associated with
osmotic diuresis. Patients also experience polyphagia (increased appetite) that
results from the catabolic state induced by insulin deficiency and the
breakdown of proteins and fats (Norris, 2019).
-Other symptoms include fatigue and weakness, sudden vision changes,
tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are
slow to heal, and recurrent infections. The onset of type 1 diabetes may also be
associated with sudden weight loss or nausea, vomiting, or abdominal pains, if
DKA has developed.
 Criteria for the Diagnosis of Diabetes

•Symptoms of diabetes plus casual plasma glucose concentration equal to or greater than 200 mg/dL (11.1
mmol/L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms
of diabetes include polyuria, polydipsia, and unexplained weight loss.
•Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric
intake for at least 8 hours.
•Two-hour postload glucose equal to or greater than 200 mg/dL (11.1 mmol/L) during an oral glucose
tolerance test. The test should use a glucose load containing the equivalent of 75-g anhydrous glucose
dissolved in water.
•Hemoglobin A1C ≥6.5% (48 mmol/mol). 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. A1C, glycosylated hemoglobin

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Assessment and Diagnostic Findings
-An
abnormally high blood glucose level is the basic criterion for the
diagnosis of diabetes. Fasting plasma glucose (FPG) (blood glucose
determination obtained in the laboratory after fasting for at least 8 hours),
random plasma glucose, and glucose level 2 hours after receiving glucose (2-
hour postprandial load) may be used (Fischbach & Fischbach, 2018). See Chart
46-2 for the ADA’s diagnostic criteria for diabetes (ADA, 2020). In addition to
the assessment and diagnostic evaluation performed to diagnose diabetes,
ongoing specialized assessment of patients with known diabetes and evaluation
for complications in patients with newly diagnosed diabetes are important
components of care

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Medical Management
-The main goal of diabetes treatment is to normalize insulin activity
and blood glucose levels to reduce the development of complications.
Intensive treatment is defined as 3 or 4 insulin injections per day or an
insulin pump (i.e., a continuous subcutaneous insulin infusion) plus
frequent blood glucose monitoring and weekly contacts with diabetes
educators (DCCT, 1993).

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 Intensive therapy must be initiated with caution and must be
accompanied by thorough education of the patient and
family and by responsible behavior of the patient.
• The therapeutic goal for diabetes management is to achieve euglycemia (normal blood glucose
levels) without hypoglycemia while maintaining a high quality of life. Diabetes management
has five components: nutritional therapy, exercise, monitoring, pharmacologic therapy, and
education.
• Blood glucose monitoring is a cornerstone of diabetes management, and self-monitoring of
blood glucose (SMBG) levels have dramatically altered diabetes care. SMBG is a method of
capillary blood glucose testing in which the patient pricks their finger and applies a drop of
blood to a test strip that is read by a meter. It is recommended that SMBG occurs when
circumstances call for it (e.g., before meals, snacks, exercise) for many patients taking insulin
(ADA, 2020)

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Nursing Management
-Nursing management of patients with diabetes can involve treatment of
a wide variety of physiologic disorders, depending on the patient’s health
status and whether the patient is newly diagnosed or seeking care for an
unrelated health problem. Glucose control in patients diagnosed with
diabetes as well as those who have not been diagnosed is an important
consideration in the hospital setting. all patients with diabetes must master
the concepts and skills necessary for long-term management and avoidance
of potential complications of diabetes, a solid educational foundation is
necessary for competent self-care and is an ongoing focus of nursing care

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CLASSIFICATION OF
DIABETES MELLITUS
 Type 1 (formerly juvenile diabetes, or
insulin-dependent diabetes)
- A state characterized by the destruction of the beta cells in the
pancreas that usually leads to absolute insulin deficiency.
a. Immune-mediated diabetes mellitus results from autoimmune
destruction of the beta cells. This is an abnormal response in which
antibodies are directed against normal tissues of the body, responding to
these tissues as if they were foreign.
b. Idiopathic type 1 refers to forms that have no known cause.

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 CAUSE/ FACTOR:
Although the events that lead to beta-cell destruction are not fully
understood, it is generally accepted that a genetic susceptibility is a
common underlying factor in the development of type 1 diabetes. People
do not inherit type 1 diabetes itself but rather a genetic predisposition, or
tendency, toward the development of type 1 diabetes. Its onset is abrupt.
It represents 5% to 10% of the cases of diabetes

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 Clinical Characteristics and
Implications (type 1 diabetes)
•Onset any age, but usually young (<30 yrs old)
•Usually thin at diagnosis; recent weight loss
•Etiology includes genetic, immunologic, and environmental factors (e.g., virus)
•Often have islet cell antibodies
•Often have antibodies to insulin even before insulin treatment
•Little or no endogenous insulin
•Need exogenous insulin to preserve life
•Ketosis prone when insulin absent
•Acute complication of hyperglycemia: diabetic ketoacidosis

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 Type 2 (formerly adult-onset diabetes, or
non–insulin-dependent diabetes)
- A state that usually arises because of insulin resistance combined
with a relative deficiency in the production of insulin. This results
because of failure of pancreatic beta cells to produce sufficient
amounts of insulin as well as resistance of the body to the effects of
insulin.
- Its onset is slow and gradual, with many individuals having had
the disease 10 years before diagnosis.

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 The two main problems related to insulin in type 2 diabetes are insulin
resistance and impaired insulin secretion. Insulin resistance refers to a
decreased tissue sensitivity to insulin. Normally, insulin binds to special
receptors on cell surfaces and initiates a series of reactions involved in
glucose metabolism. In type 2 diabetes, these intracellular reactions are
diminished, making insulin less effective at stimulating glucose uptake by the
tissues and at regulating glucose release by the liver. The exact mechanisms
that lead to insulin resistance and impaired insulin secretion in type 2
diabetes are unknown, although genetic factors are thought to play a role.

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 Clinical Characteristics and
Implications
•Onset any age, usually ≥30 yrs
•Usually obesity is present at diagnosis
•Causes include obesity, heredity, and environmental factors
•No islet cell antibodies
•Decrease in endogenous insulin, or increased with insulin resistance
•Most patients can control blood glucose through weight loss if they have obesity
•Oral antidiabetic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful
•May need insulin on a short- or long-term basis to prevent hyperglycemia
•Ketosis uncommon, except in stress or infection
•Acute complication: hyperglycemic hyperosmolar syndrome

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Gestational diabetes
 - A condition of abnormal glucose metabolism that arises during pregnancy.
Possible signal of an increased risk for type 2 diabetes later in life. It is any degree of
glucose intolerance with its onset during pregnancy (Norris, 2019). Hyperglycemia
develops during pregnancy, particularly in the second and third trimesters, because of
the secretion of placental hormones that cause insulin resistance.

- After delivery, blood glucose levels in women with gestational diabetes usually
return to normal. However, many women who have had gestational diabetes develop
type 2 diabetes later in life. Women with a history of gestational diabetes should be
screened for the development of diabetes or prediabetes every 3 years (ADA, 2020).

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 Clinical Characteristics and
Implications
•Onset during pregnancy, usually in the second or third trimester Because of hormones secreted
by the placenta, which inhibit the action of insulin
•Above-normal risk for perinatal complications, especially macrosomia (abnormally large babies)
•Treated with diet and, if needed, insulin to strictly maintain normal blood glucose levels
•Occurs in about 18% of pregnancies
•Glucose intolerance transitory but may recur:
•- In subsequent pregnancies
•- 35–60% will develop diabetes (usually type 2) within 10– 20 yrs, especially if they have
obesity

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Causes:
Risk factors for developing
gestational diabetes include:
 • Obesity
• History of large babies (10 lb or more)
• History of unexplained fetal or perinatal loss
• History of congenital anomalies in previous pregnancies
• History of polycystic ovary syndrome
• Family history of diabetes (one close relative or two distant ones)
• Member of a population with a high risk for diabetes (Native American, Hispanic, Asian)
• Antagonizing of insulin effects caused by some medications, including thiazide diuretics,
adrenal corticosteroids, and hormonal contraceptives
• Physiologic or emotional stress elevating stress hormone levels (cortisol, epinephrine,
glucagon, and growth hormone), thereby raising blood glucose levels
* Pregnancy-related increased levels of estrogen and placental hormones, which antagonize
insulin

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Signs and
Symptoms
 • Ketoacidosis or insidious onset in type I
• Most commonly, fatigue from energy deficiency and a catabolic state
• Occasionally, no symptoms (in patients with type 2 diabetes)
• Osmotic diuresis evident with poly-uria, dehydration, polydipsia, dry
mucous membranes, and poor skin turgor
• In ketoacidosis and hyperglycemic hyperosmolar nonketotic state,
dehydration potentially leading to hypovolemia and shock.
• Weight loss and hunger in uncontrolled type 1 diabetes, even if the patient
eats voraciously Long-term effects

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 • Retinopathy
• Nephropathy a Atherosclerosis
• Peripheral neuropathy, usually of the hands and feet
- Autonomic neuropathy, possibly as gastroparesis leading to delayed
gastric emptying and a feeling of nausea and Auliness after meals),
nocturnal diarrhea, impotence, and postural hypotension
• Skin and urinary tract infections and vaginitis

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Assessment
 • All women should be screened during pregnancy for gestational diabetes.
- a fasting plasma glucose greater than or equal to 126 mg/dl or a non-fasting plasma
glucose greater than or equal to 200 mg/dl meets the threshold for the diagnosis of
diabetes and does not need confirmation. It is recommended that all pregnant women
receive a 50-g glucose challenge test between 24- and 28-weeks’ gestation to determine if
they are at risk for gestational diabetes. If the result of that test is 140 mg/dI (some
providers use 130 mg/dl as the cutoff, then the woman will need to do a three-hour
glucose tolerance test.
• After a fasting glucose sample is obtained, the woman drinks an oral 100-g
glucose solution
- a venous blood sample is then taken for glucose determination at 1, 2, and 3 hours later. If
two of the four blood samples collected for this test are abnormal or the fasting value is
above 95 mg/d, a diagnosis of diabetes is made.

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Diagnosis
 The following nursing diagnosis and related interventions illustrate one of
the most important facets of the nurse's role in caring for the pregnant
woman with diabetes: health teaching. Important topics include nutrition,
exercise, insulin administration, blood glucose monitoring, and
explanations of the various fetal assessment tests 6 weeks that will be done.

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Nursing Diagnoses and Related Interventions because diabetes is such a complicated complex
disorder, associated nursing diagnoses are many and varied. Examples include:

• Risk for ineffective tissue perfusion related to reduced vascular flow .

• Imbalanced nutrition, less than body requirements, related to inability to use glucose
• Risk for ineffective coping related to required change in lifestyle
• Risk for infection related to impaired healing accompanying condition
• Deficient fluid volume related to polyuria accompanying the disorder
• Deficient knowledge related to complex health problem
• Health-seeking behaviors related to voiced need to learn home glucose monitoring
• Deficient knowledge related to a ter to detect therapeutic regimen necessary during
pregnancy

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Therapeutic
Management
 • Blood glucose levels near normal help minimize the
risk of maternal and fetal complications, both women
with gestational diabetes and those with overt diabetes
need more frequent prenatal visits than usual to ensure
close monitoring of their condition and that of the
fetus.

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thank you