DIABETES

MELLITUS
By: CHARLEMAGNE B. PULGAN, RN
MEDICAL MANAGEMENT

MAIN GOAL:
to normalize insulin activity and blood glucose
levels to reduce the development of complications
Therapeutic Goal:
to achieve normal blood glucose levels
(euglycemia) without hypoglycemia while
maintaining a high quality of life.
• patient and family education is an essential component
of diabetes treatment
• Diabetes management has five components:
1. nutritional therapy/diet
2. exercise
3. monitoring
4. pharmacologic therapy
5. education
 1. NUTRITIONAL
THERAPY/DIET
• Nutrition, meal planning, weight control, and increased activity
are the foundation of diabetes management
• Most important objectives:
control of total caloric intake to attain
maintain a reasonable body weight
control of blood glucose levels; and
Normalization of lipids and blood pressure to prevent heart
disease
• Medical Nutrition Therapy (MNT)
nutritional therapy prescribed for the management of
diabetes is usually given by a registered dietician
• For diabetics and obese
weight loss is the key to treatment
a. Overweight – BMI 25-29
b. Obese –BMI greater than or equal to 30
--20% above ideal body weight
• For patients who are obese, have diabetes, and do not
take insulin or sulfonylureas

a. Consistent meal content or timing is important

b. decreasing the overall caloric intake is of greater
importance
c. meals should not be skipped
 A. MEAL PLANNING AND RELATED
EDUCATION
• The meal plan must consider the patient’s food preferences,
lifestyle, usual eating times, and ethnic and cultural
background.
• The nurse plays an important role in communicating
pertinent information to the dietitian and reinforcing the
patient’s understanding.
• Communication between the team is important.
A.1 CALORIC REQUIREMENTS

• Calorie-controlled diets are planned by first

calculating a person’s energy needs and caloric
requirements based on age, gender, height, and
weight.
• The calories are distributed into carbohydrates,
proteins, and fats, and a meal plan is then developed,
taking into account the patient’s lifestyle and food
preferences.
A.2 CALORIC DISTRIBUTION
A meal plan for diabetes focuses on the percentages of calories
that come from carbohydrates, proteins, and fats.
A.CARBOHYDRATES (50%)
caloric distribution currently recommended is higher in
carbohydrates
Carbohydrate foods have the greatest effect on blood glucose
levels because they are more quickly digested than other foods and
are converted into glucose rapidly
recommend that all carbohydrates should be eaten in moderation
to avoid high post-prandial blood sugar
B. FATS (30%)

• recommendations include:
reducing the total percentage of calories from fat sources to
less than 30% of total calories ;
limiting the amount of saturated fats to 10% of total calories
• additional recommendations include limiting the total intake of
dietary cholesterol to less than 300 mg/day;
• help reduce risk factors such as increased serum cholesterol
levels, which are associated with the development of coronary
artery disease
C.PROTEIN (20%)

The meal plan may include the use of some non-

animal sources of protein (e.g., legumes, whole
grains) to help reduce saturated fat and cholesterol
intake
In addition, the amount of protein intake may be
reduced in patients with early signs of kidney
disease
D. FIBER

• High Fiber Diet, especially vegetables

improve blood glucose levels
decrease the need for exogenous insulin
lower total cholesterol and low-density lipoprotein levels
in the blood
• At least 25 g of fiber should be ingested daily
• Diabetic patients should not eat as much as they want
A.3 FOOD CLASSIFICATION SYSTEM

1. EXCHANGE LISTS
A commonly used tool for nutritional management
There are six main exchange lists: bread/starch, vegetable,
milk, meat, fruit, and fat
Foods on one list may be interchanged with one another,
allowing for variety while maintaining as much consistency as
possible in the nutrient content of foods eaten
2. NUTRITION LABELS
Food manufacturers are required to have the
nutritional content of foods listed on their packaging
Reading food labels is an important skill for patients
to learn
The label includes information about how many
grams of carbohydrates are in a serving of food
This information can be used to determine how
much medication is needed.
A.4 OTHER DIETARY CONCERNS

1. ALCOHOL CONSUMPTION
Alcohol is absorbed before other nutrients and does not require
insulin for absorption
Large amounts can be converted to fats, increasing the risk for
DKA
Alcohol may decrease the normal physiologic reactions in the
body that produce glucose (gluconeogenesis)
Alcohol consumption may lead to excessive weight gain
2. SWEETENERS
• use of artificial sweeteners is acceptable, especially if it
assists in overall dietary adherence
• There are two main types of sweeteners:
nutritive sweeteners –contains calories; less elevation in
blood sugar levels
non-nutritive- have few or no calories; they are used
in food products; they produce minimal or no
elevation in blood glucose level
3. MISLEADING FOOD LABELS
• Foods labeled “sugarless” or “sugar-free” may still provide
calories equal to those of the equivalent sugar-containing
products
• Foods labeled “dietetic” are not necessarily reduced-calorie
foods
• Patients must read the labels of “healthy foods”—especially
snacks— because they often contain carbohydrates (e.g.,
honey, brown sugar, corn syrup, flour) and saturated vegetable
fats (e.g., coconut or palm oil)
 2. ACTIVITY AND EXERCISE
• The benefits of a regular pattern of exercise
increases glucose uptake by the cells
lowers insulin requirements
helps achieve desirable body weight
helps maintain normal serum lipids
improves circulation and muscle tone
increase lean muscle mass
useful in diabetes in relation to losing weight, easing stress,
and maintaining a feeling of well-being
General Considerations for Exercise in People With
Diabetes
The nurse instructs the patient to:
• Exercise three times each week with no more than 2
consecutive days without exercise
• Perform resistance training twice a week if you have type 2
diabetes
• Exercise at the same time of day (preferably when blood
glucose levels are at their peak) and for the same duration
each session
• Instruct client to monitor blood glucose before, during and
after the exercise period
• Use proper footwear and, if appropriate, other
protective equipment
• Avoid trauma to the lower extremities, especially if
you have numbness due to peripheral neuropathy
• Inspect feet daily after exercise
• Avoid exercise in extreme heat or cold
• Stretch for 10 to 15 minutes before exercising
 2.1 EXERCISE
RECOMMENDATIONS
• Exercise recommendations must be altered as necessary for patients
with diabetic complications
• In general, a slow, gradual increase in the exercise period is
encouraged
• should discuss an exercise program with their primary provider
• an exercise stress test is recommended before starting an exercise
program for patients older than 30 and with 2 risk factors for heart
disease (An abnormal stress test may indicate cardiac ischemia)
 2.2 EXERCISE
PRECAUTIONS
• Patients who have blood glucose levels exceeding 250 mg/dL
(14 mmol/L) and who have ketones in their urine should not
begin exercising
• eat a 15-g carbohydrate snack (a fruit exchange) or a snack of
complex carbohydrates with a protein before engaging in
moderate exercise
• the patient may need to eat a snack at the end of the exercise
session and monitor blood sugar level to prevent post-
exercise hypoglycemia
 3. MONITORING GLUCOSE
LEVELS
Blood glucose monitoring
cornerstone of diabetes management
• 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
a. detection and prevention of hypoglycemia and
hyperglycemia
b. plays a crucial role in normalizing blood glucose levels
Risk and source errors for SMBG
a. improper application of blood (drop to
small)
b. Damage reagent strips
c. Use of outdated strips
d. Improper meter cleaning and maintenance
NURSE EDUCATION on SMBG TECHNIQUES
A.Evaluating the techniques of the patient who are
experienced in self-monitoring
B.Every 6-12 months, the patient should conduct a
comparison of their meter results with a simultaneous
laboratory-measured blood glucose level
C.Strips accuracy of the meter can also be assessed with
control solutions
CANDIDATES FOR SELF-
MONITORING of BLOOD GLUCOSE
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
A. For most patients who require insulin: two to four times
daily
B. For patients who take insulin before each meal: at least
three times daily before meals to determine each dose
C. Those not receiving insulin: at least two or three times per
week, including a 2-hour postprandial test
D. For all patients: testing is recommended whenever
hypoglycemia or hyperglycemia is suspected
. PHARMACOLOGIC THERAPY
1. INSULIN THERAPY
A.Type 1 DM - it must be given for life because
of the inability to produce insulin.
B.Type 2 DM- insulin may be given on a long-
term basis if meal planning and oral agents are
ineffective
Special Consideration
Regular insulin is the only insulin that Check if the patient
can be administered intravenously in the is taking:
emergency treatment of diabetic Glucocorticoids,
ketoacidosis thiazide diuretics,
Take extra caution with:
thyroid agents,
Aspirin
alcohol oral contraceptives,
oral anticoagulants estrogen
oral hypoglycemic drugs
beta-adrenergic blockers,
tricyclic antidepressants, tetracycline
and MAOl’s
A.TIME COURSE OF ACTION
1. ONSET- is the length of time before insulin reaches
the bloodstream and begins lowering blood sugar
2. PEAK- is the time during which insulin is at
maximum strength in terms of lowering blood sugar
3. DURATION- is how long insulin continues to
lower blood glucose
B. Categories of INSULIN
1.RAPID ACTING
• insulins produce a more rapid effect that is of
shorter duration than regular insulin
• Because of their rapid onset, the patient should be
instructed to eat no more than 5 to 15 minutes
after injection
2. SHORT-ACTING
• are called Regular insulin (marked R on the bottle)
• Regular insulin is a clear solution and is usually given
15 minutes before a meal
• either alone or in combination with a longer-acting
insulin
• Regular insulin is the only insulin that can be
administered IV
3. INTERMEDIATE-ACTING
• are called NPH insulin (neutral protamine Hagedorn)
or Lente insulin
• appear white and cloudy
• If NPH or Lente insulin is taken alone, it is not
crucial that it be taken before a meal but patients
should eat some food around the time of the onset
and peak of these insulins
4. LONG-ACTING
• “Peakless” basal insulin; the insulin is absorbed very slowly over
24 hours and can be given once a day
• Because the insulin is in a suspension with a pH of 4, it cannot
be mixed with other insulins because this would cause
precipitation
• it has now been approved to be given once a day at any time of
the day but must be given at the same time each day to prevent
overlap of action
5. PREMIXED INSULIN
• a combination of two insulins mixed together, one
rapid or short-acting and one intermediate-acting or
long-acting.
1. RAPID- ONSET PEAK DURATION
ACTING
INSULIN
A. HUMALOG 15 ½ -1 ½ 3-5 HOURS
(LISPRO) MINUTES HOURS

B. NOVOLOG 5-10 1-2 3-5 HOURS

(INSULIN MINUTES HOURS
ASPART)
2. SHORT- ONSET PEAK DURATION
ACTING
INSULIN

A. REGULAR ½ - 1 HOUR 2-4 5-8 HOURS

INSULIN HOURS
(HUMULIN R or
NOVOLIN R)
3. ONSET PEAK DURATION
INTERMEDIATE-
ACTING INSULIN
A. NPH (HUMULIN N 1-2 4-12 14-18
or NOVOLIN N) HOURS HOURS HOURS

B. LENTE (HUMULIN 1-3 4-12 14-18

L; NOVOLIN L) HOURS HOURS HOURS
4. LONG-ACTING ONSET PEAK DURATION
INSULIN

A. ULTRALENTE 6 No Peak 24 HOURS

(HUMULIN U)/ HOURS
LEVEMIR

B. INSULIN 4-8 No Peak 24-36

GLARGINE HOURS HOURS
(LANTUS)
5. PREMIXED ONSET PEAK DURATION
INSULIN
A. HUMULIN 70/30 (70% ½ HOUR 2-12 HOURS 18-24
NPH/30% REGULAR) HOURS

B. HUMULIN 50/50 (50% ½ HOUR 3-5 HOURS 24 HOURS

NPH/50% REGULAR)

C. LISPRO/PROTAMINE 10-15 1-6 HOURS 24 HOURS

75/25 (75% LISPRO/25% MINUTE
PROTAMINE) S
NURSING RESPONSIBILITY IN INSULIN
THERAPY
1. The main route of insulin injection is subcutaneous. There are
lesser blood vessels and nerves in the subcutaneous areas.
2. The main areas for insulin injections are the abdomen, arms
(posterior surface), thighs (anterior surface), and buttocks.
3. Administer insulin at 90°L. Most insulin syringes have needle
gauge 27 to 29, that is about ½ inch long.
4. Do not massage injection site
5. Systematic rotation of the site of injection. Reuse one site after at
least 2 to 3 weeks.
6. Administer insulin at room temperature not in cold
7. Gently roll the vial in between the palms to redistribute
insulin particles.
8. Do not shake the vial
9. Storing Insulin:
Prefilled insulin syringes should be kept in the refrigerator.
These will be potent for 7 days (1 week).
If a vial of insulin will be used up in 30 days it may be kept
at room temperature. Otherwise, the vial should be
refrigerated.
Avoid exposing insulin to extremes of temperature.
Insulin should not be frozen or kept in direct sunlight or a hot
car.
10.Regular insulin may be mixed with any other type of insulin
to mix insulins, the following nursing actions are done:
Introduce air into the vial of intermediate–acting insulin (e.g.
NPH). Do not aspirate/draw up the Insulin yet
Introduce air into the vial of regular insulin, and draw up the
insulin.
Draw up the intermediate-acting insulin (NPH).

!!!Remember: Draw up the regular insulin first.

13.Monitor client for complications of insulin therapy:
a.Local allergic reactions
b.Insulin lipodystrophy
c.Dawn phenomenon
d.Somogyi effect
e.Insulin waning
COMPLICATIONS OF INSULIN
THERAPY
A. SYSTEMIC ALLERGIC REACTIONS
immediate local skin reaction that gradually spreads into
generalized urticaria (hives)
Redness, swelling, tenderness, and induration or a wheal
at the site of injection may occur 1 to 2 hours after
administration
Administer antihistamine one hour before injection as
prescribed by the physician
B. INSULIN LIPODYSTROPHY
refers to a localized reaction, in the form of either
lipoatrophy or lipohypertrophy, occurring at the site of
insulin injections.
a. Lipoatrophy is the loss of subcutaneous fat
b. Lipohypertrophy the development of fibrofatty
masses at the injection site, is caused by the repeated
use of an injection site.
 C. DAWN PHENOMENON

Relatively normal blood glucose until about 3 am, when the

glucose level begins to RISE
Results from the reduced tissue sensitivity to insulin that
develops between 5:00 and 8:00 AM (prebreakfast
hyperglycemia)
 Management: Treatment is administering intermediate-acting
insulin (NH) at 10 PM to control early morning
hyperglycemia
D. SOMOGYI EFFECT
Normal or elevated blood glucose at bedtime,
decrease blood glucose at 2-3 am due to hypoglycemic
levels, and a subsequent increase in blood glucose in
the morning (rebound hyperglycemia)
Management- decrease the evening dose of
intermediate-acting insulin NPH or increase the
bedtime snack
E. INSULIN WANING
Progressive rise in blood glucose from bedtime
to morning
Seen when the NPH evening dose is
administered before dinner
Management: Move the insulin injection to
bedtime or increase the evening dose of
intermediate-acting insulin
\
 METHODS OF INSULIN
DELIVERY
1. Insulin Pens

 Insulin pens use small (150- to 300-unit) prefilled

insulin cartridges that are loaded into a pen-like
holder.
These devices are most useful for patients who need
to inject only one type of insulin at a time
These pens are convenient for those who administer
insulin before dinner if eating out or traveling
2. JET INJECTORS
an alternative to needle injections, jet injection devices
deliver insulin through the skin under pressure in an
extremely fine stream
Insulin given by jet injector is usually absorbed faster
These devices are more expensive and require thorough
training and supervision when first used
3. INSULIN PUMPS
Continuous subcutaneous insulin infusion
Insulin pumps contain a 3-mL syringe attached to a long thin, narrow-
lumen tube with a needle or Teflon catheter attached to the end
The patient inserts the needle or catheter into subcutaneous tissue
(usually on the abdomen) and secures it with tape or a transparent
dressing.
The needle or catheter is changed at least every 3 days.
The pump is then worn either on the patient’s clothing or in a pocket
Possible disadvantages of insulin pumps
• unexpected disruptions in the flow of insulin from the pump that
may occur if the tubing or needle becomes occluded
• if the supply of insulin runs out, or if the battery is depleted,
increasing the risk of DKA
• There is the potential for infection at needle insertion sites
• patients find that wearing the pump for 24 hours each day is
inconvenient
2. ORAL HYPOGLYCEMIC AGENTS
Stimulating Islet of Langerhans to secrete insulin
Increase the sensitivity of peripheral receptors to
insulin
Decrease hepatic glucose output or delay intestinal
absorption of glucose
This decreases serum glucose levels
Indicated only in TYPE 2 DM
 1. SULFONYLUREAS
Lowers blood sugar by stimulating the release of insulin by the beta
cells of the pancreas
SULFONYLUREAS ADVERSE REACTION EXAMPLE

1. First generation are low Hypoglycemia, nausea, A. tolbutamide (Oranase)

potency and short-acting heartburn, constipation, B. chlorpropamide
anorexia, allergic skin (Diabinase)
reactions

2. Second generation are Weight gain, hypoglycemia A. Glyburide (Micronase)

higher potency and longer B. Glimepiride (Amaryl)
acting
2. BIGUANIDES

Lower serum glucose levels by

inhibiting hepatic glucose
production and increased sensitivity
of peripheral tissue to insulin
Adverse Reaction: Hypoglycemia,
Abdominal discomfort, Diarrhea
Ex; metformin ( Glucophage)
3. Alpha Glucosidase
delay the absorption of carbohydrates from
the small intestine and thus have a lowering
effect on postprandial blood glucose and insulin
levels
Adverse Reaction :Hypoglycemia
Ex: acarbose ( Precose)
miglitol ( Glycet)
4. THIAZOLIDINEDIONES
Lowers blood sugar by decreasing insulin resistance of the tissues
Adverse Reaction:
Hypoglycemia, Edema, Anemia, weight gain
Ex: Rosiglitazone ( Avandia), Pioglitazone (Actos)
Nursing Implications:
• Skip the dose if meal skipped
• Monitor liver function test
• Caution use with CAD may precipitate CHF
5. MEGLITINIDES
Lowers blood sugar by stimulating beta cells to release insulin
Adverse Reaction: Hypoglycemia, Angina, Back pain, N/V,
constipation or diarrhea
Ex: Repaglinide( Prandin)
Nursing Implications:
 Monitor blood glucose
 Give before meals, if the meal is skipped, skip the dose.
6. COMBINATIONS : glyburide + metformin
(Glucovance)
Lowers blood sugar by combining the advantages of 2 classes of
hypoglycemics
SPECIAL CONSIDERATION IN TAKING OHA

1.Aspirin, alcohol, sulfonamides, contraceptives, and

monoamine oxidase inhibitors (MAOls)
2.Glucocorticoids, thiazide diuretics, and estrogen
3.Sulfonylureas should not be taken with alcohol
4.Inderal (Propranolol) and other beta-adrenergic blockers
5.Sulfonylureas may cause cardiac dysrhythmias, GI symptoms
6.Advise the client to wear a Medic-Alert bracelet
 ACUTE COMPLICATIONS OF DIABETES
MELLITUS
A. Hypoglycemia
Occurs when blood glucose level falls below 60mg/dL
Causes of hypoglycemia are as follows
Overdose of insulin or oral hypoglycemic agents
Omission of meals or too little food
Strenuous exercise or excessive activity
Gastrointestinal upset (e.g. nausea and vomiting, diarrhea)
The client should be instructed to always carry some form of fast-
acting simple carbohydrates.
CLINICAL MANIFESTATIONS OF HYPOGLYCEMIA

1.Mild hypoglycemia: 2. Moderate hypoglycemia: blood

blood glucose level less glucose level less than 40mg/dL.
than 60mg/dL. Confusion
Hunger Double vision
Palpitations Drowsiness/Lightheadedness
Sweating Headache
Impaired coordination
Tachycardia
Inability to concentrate
Tremors
Irrational or combative behavior
Memory lapses
Numbness of the lips and tongue
Slurred speech
CLINICAL MANIFESTATIONS OF HYPOGLYCEMIA

3. Severe hypoglycemia: blood glucose level less

than 20mg/dL

Inability to swallow
Loss of consciousness
Seizure
COLLABORATIVE MANAGEMENT FOR HYPOGLYCEMIA
1. Mild hypoglycemia
Give 10 to 15 g. of fast-acting - acting simple carbohydrates:
Commercially prepared glucose tablets
6 to 10 Life Savers or hard candy
4 tsp. of sugar
 4 sugar cubes
1 Tbs. of honey or syrup
 ½ cup of fruit juice or regular soft drink (soda)
8 oz. low-fat milk
6 saltine crackers
3 graham crackers
Retest the blood glucose level in 15 minutes; repeat the
treatment if symptoms do not resolve.
Once symptoms resolve, give 2 slices of white bread (sandwich)
or crackers, then a cup of skim milk or cheese or provide a
regular meal within 60 minutes

2. Moderate hypoglycemia
Give 15 to 30g of fast-acting simple carbohydrates
Give additional food such as low-fat milk or cheese after 10 to
15 minutes
 3. Severe hypoglycemia
If unconscious or unable, to swallow, an injection of glucagon is
administered subcutaneously intramuscularly, or intravenously
Administer a second dose if the client remains unconscious.
A small meal is given to the client when he awakens as long as
he is not nauseated.
 Notify the physician if a severe hypoglycemic reaction occurs.
Administer 50% dextrose in water, 25 to 50 ml. per IV as
prescribed.
Glucagon is used to treat insulin-induced hypoglycemia when
the client is semi-conscious or unconscious and is unable to
B. Diabetic Ketoacidosis (DKA)
Is a life-threatening complication of Type I DM
This is due to severe insulin deficiency
Underdose or missed dose of insulin
Illness or infection
Overeating
Stress
Undiagnosed and untreated type I DM
CLINICAL MANIFESTATIONS OF DKA
1.Hyperglycemia (300 to 800 6.Anorexia, nausea, vomiting,
mg/dL) abdominal pain
2.Dehydration and Electrolyte 7.Blurred vision
loss 8.Headache
3.Acidosis(Low serum 9.Hypotension
bicarbonate and a low pH are
present) 10.Mental status changes
4.Acetone breath (fruity odor) 11.Polydipsia
5. Kussmaul’s Respiration 12.Polyuria
13.Weak, rapid pulse
14.Weakness
COLLABORATIVE MANAGEMENT FOR DKA
1. Maintain patent airway
2. Administer oxygen therapy as prescribed
3. Treat dehydration with Normal Saline 0.9% or 0.45% rapid IV as
prescribed
4. D5NS or 5% dextrose in 0.45% saline when the blood glucose level
reaches 250 to 300 mg/dL.
5. Treat hyperglycemia with regular insulin /IV as prescribed.
6. Mix the prescribed IV dose of regular insulin for continuous
infusion in 0.9% or 0.45% saline as prescribed.
7. Small dose of albumin may be mixed with the insulin and saline
solution
9.Monitor glucose levels, urinary output and for signs of
increased intracranial pressure (ICP)
If blood glucose severely drops too fast before the brain can
equilibrate, water is pulled from the blood to the cerebrospinal
fluid and the brain.
This causes cerebral edema and increased ICP
10.Monitor potassium and correct electrolyte imbalances
potassium level may be elevated as a result of acidosis and
dehydration)
Serum potassium levels will fall rapidly as dehydration and
acidosis are treated.
11. Potassium, replacement(e.g.KCl, K - Rider) may be required.
 Ensure adequate renal function (e.g. urine output of 30 to 60
ml/hr before administering potassium.
If there's no adequate urine output, don’t administer potassium
supplements. (NO PEE, NO K)

NOTE!!!
The maximum amount of Potassium Chloride (KCI) that may be
mixed with 1 liter of IV fluid is 40mEq
The maximum amount of potassium supplement that may be
given per IV infusion is 10mEq/hour
Always use IV infusion pump for potassium infusion
C. Hyperglycemic Hyperosmolar Nonketotic Syndrome
(HHNS)
Is severe hyperglycemia that occurs without ketosis and
acidosis
The syndrome occurs in Type II diabetics

Clinical manifestations of HHNS

1. Blood glucose 600 to 2,000mg/dl
2. Hypotension 5. mental status change
3. Dehydration 6. Neurologic deficits
4. Tachycardia 7. Seizures
COLLABORATIVE MANAGEMENT FOR HHNS
1.Treatment similar to DKA:
Fluid replacement
Correction of Electrolyte Imbalance
Insulin administration
 CHRONIC COMPLICATIONS OF DIABETES
MELLITUS
A. Diabetic Retinopathy
Is chronic and progressive impairment of the retinal circulation
that eventually causes hemorrhage.
 Permanent blindness can occur.

Clinical Manifestation
rupture of microaneurysms in retinal blood vessels causes a
change in vision
Blurred vision due to macular damage
Sudden loss of vision due to retinal detachment
Cataracts from lens opacity
Collaborative Management
Maintain safety
Control hypertension and blood glucose levels
Laser therapy to remove hemorrhagic tissue to decrease
scarring
Vitrectomy to remove vitreous hemorrhage and prevent retinal
detachment
 Cataract removal
B. Diabetic Nephropathy
Is the progressive loss of kidney function

Clinical Manifestation
Microalbuminuria
Thirst
Fatigue
Anemia
Weight loss, malnutrition
 Frequent urinary tract infection (UTI)
Signs of neurogenic bladder
Collaborative Management

Control of hypertension and blood glucose levels.

 Monitor VS, intake and output, serum BUN and creatinine,
and urine albumin levels
Restrict dietary protein, sodium, and potassium intake as
needed
Prepare the client for dialysis, kidney transplant, or pancreas
transplant as prescribed
C. Diabetic Neuropathy
• is a general deterioration of the nervous system throughout the body
• Complications include: non-healing ulcers of the feet, gastroparesis,
erectile dysfunction
Clinical Manifestation
Paresthesia
Decreased or absent reflexes
Diminished sensation, peripheral pulses
Pain, aching, and burning in the lower extremities
Skin breakdown and signs of infection
Dizziness
Impotence
Collaborative Management

Control of hypertension and blood glucose levels

Administer pain medications as prescribed
Initiate a bladder training program (for neurogenic bladder)
Penile injection or implantable devices as prescribed (Consider
religious and cultural beliefs)
Collaborative Management
Foot care to prevent trauma and prevent gangrene formation
Inspect the feet daily
Wash feet with warm water and mild soap.
Moisturize your feet and ankles with lotion or
petroleum jelly
Avoid foot soaking.
Wear a comfortable, properly fitted pair of shoes (leather or
canvass; although leather is preferred)
Do not wear open-toed shoes or shoes with a strap that goes
between the toes.
Check shoes for cracks or tears in the lining and for foreign
objects before putting them on.
Collaborative Management
 Do not go barefooted
 wear clean cotton socks daily
Trim toenails straight across or follow the curve of the toe. Do not cut
at lateral edges to prevent the development of ingrown. Smoothen nails
with an emery board
Apply lotion to the feet but not between the toes
Do not cross legs or wear tight garments that may constrict blood flow.
For any signs and symptoms of injury, notify physician
Avoid use of hot water, heating pads
Exercise and massage the feet
Do not smoke
GESTATIONAL DIABETES

Onset: during pregnancy, usually second and third trimesters

Etiology: linked to hormones secreted in the placenta that
inhibit the action of Insulin
Risk factors: obesity, age above 30, family history,
previous large babies (> 9 pounds)
Incidence: 18% of pregnancies; increased risk for
Hypertension
Treatment:
treated with diet and if needed, insulin therapy to
maintain normal blood glucose
Screening test (glucose challenge test GCT or
OGTT) should be performed on all pregnant women
between 24-28 weeks of gestation
Should be screened for diabetes periodically (first
prenatal visit)
High Risk if GCT results in value of 140mg/dl (7.8mmol/L)
Goals during pregnancy:
-Blood glucose level 95-120mg/dl (5.3 – 6.72mmol/L)

!!!NOTE
After delivery, blood glucose level in GDM returns to
normal. However, many women who have GDM develops
(DM Type II) later in life.
35-60% who had GDM develops diabetes in the next 10-
20 years
 4. LATENT
AUTOIMMUNE
DIABETES OF ADULT
In adults, LADA is a subtype of diabetes
the progression of autoimmune beta cell destruction in the pancreas is
slower than in types 1 and 2
Patients with LADA are not insulin-dependent in the initial 6 months
of disease onset.
Clinical manifestation of LADA shares the features of types 1 and 2
diabetes