Nursing Care 1: NURS14178
Module 2: Endocrine System Health
Problems: Diabetes
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MODULE 2
Diabetes Mellitus (DM)
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Diabetes mellitus is a chronic multisystem disease related to
o Insufficient or abnormal insulin production
o Impaired insulin utilization
o Or both
Approximately 65% to 80% of people with DM die as a result of
heart disease or stroke
DM is a contributing factor in the deaths of approximately 41,500
Canadians each year
If left untreated, DM can lead to:
o Diabetic Retinopathy
o Diabetic Peripheral Neuropathy
o Diabetic Nephropathy
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MODULE 2
Etiology and Pathophysiology
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Theories link cause to a single and/or a
combination of these factors
o Genetic
o Autoimmune
o Viral
o Environmental
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Etiology and Pathophysiology
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Normal insulin metabolism
o Produced by the  cells
o Islets of Langerhans
Released continuously into bloodstream in small increments with
larger amounts released after food is ingested
Stabilizes glucose range to 4 - 6 mmol/L
© 2019 Elsevir Canada, a division of Reed Elsevier Canada, Ltd.
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Etiology and Pathophysiology
Insulin
 Promotes glucose transport from bloodstream across
cell membrane to cytoplasm of cell
 Decreases glucose in the bloodstream
 ↑ insulin after a meal
o Stimulates storage of glucose as glycogen in liver
and muscle
o Inhibits gluconeogenesis
o Enhances fat deposition
o ↑ protein synthesis
 Skeletal muscle and adipose tissue - Insulin-dependent
tissues
© 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Etiology and Pathophysiology
Two most common types
 Type 1
 Type 2
Other types
 Gestational
 Prediabetes
 Secondary diabetes
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Type 1 Diabetes
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Occurs more frequently in younger children
Most often occurs in people younger than 30 years of age
Autoimmune condition
Pancreas is unable to produce insulin
May be caused by genetic predisposition
Daily injections of insulin are needed
Also referred to as Insulin Dependent Diabetes Mellitus
(IDDM) or Juvenile Diabetes
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Type 1 Diabetes – Etiology and Pathophysiology
End result of longstanding process
 Progressive destruction of pancreatic -cells by body’s own T cells
 Autoantibodies cause a reduction of 80% to 90% in normal -cell
function before manifestations occur
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Type 1 Diabetes
Onset of disease
 Long pre-clinical period
 Antibodies present for months to years before symptoms occur
 Manifestations develop when pancreas can no longer produce
insulin
 Rapid onset of symptoms
 Present at ED with ketoacidosis
 Will require exogenous insulin to sustain life
 Diabetic ketoacidosis (DKA) - Life-threatening condition
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MODULE 2
Prediabetes
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Individuals already at risk for diabetes
Characterized by
o Impaired fasting glucose (IFG)
o Impaired glucose tolerance (IGT)
Blood glucose high but not high enough to be diagnosed as having
diabetes (6.1–6.9 mmol/L for IFG and 7.1–11 mmol/L for IGT
Long-term damage already occurring
o Heart, blood vessels
Usually present with no symptoms
Must watch for diabetes symptoms
o Polyuria
o Polyphagia
o Polydipsia
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Type 2 Diabetes
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Usually develops in adulthood (above 35 years)
Most prevalent type of diabetes
Pancreas does not produce enough insulin or body cells do not
properly use the insulin
Glucose remains in the bloodstream
As insulin is not always necessary for treatment, it is known as
Non-Insulin Dependent Diabetes Mellitus (NIDDM) or AdultOnset Diabetes
Prevalence increases with age
Genetic basis
Greater in some high-risk populations
o Increased rate in people of Indigenous, Hispanic, South
Asian, Asian, or African descent
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Type 2 Diabetes – Etiology and Pathophysiology
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Pancreas continues to produce some endogenous insulin
Insulin produced is insufficient or is poorly utilized by tissues
Obesity (abdominal/visceral)
o Most powerful risk factor
Genetic mutations
o Lead to insulin resistance
o Increased risk for obesity
Individuals with metabolic syndrome are at risk for:
o Cardiovascular diseases, hypertension, dyslipidemia, insulin
resistance, and dysglycemia
Risk factors
o Abdominal obesity, sedentary lifestyle, urbanization, certain
ethnicities
© 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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MODULE 2
Type 2 Diabetes
Onset
 Gradual onset
 Person may go many years with undetected hyperglycemia
 Osmotic fluid/electrolyte loss from hyperglycemia may become
severe.
o Hyperosmolar coma
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MODULE 2
Gestational Diabetes
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Temporary condition that develops during pregnancy
Due to fluctuations of hormone levels
Detected at 24 - 28 weeks of gestation
Woman with gestational diabetes are at high risk for type 2
diabetes
Usually normal glucose levels at 6 weeks postpartum
Increased risk for birth trauma, hypoglycemia,
hyperbilirubinemia, and respiratory distress syndrome
Increased risk for developing type 2 diabetes in 5 - 10
years
Therapy: first nutritional, second insulin
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Secondary Diabetes
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Medications that causes abnormal blood glucose level
o Corticosteroids (prednisone)
o Phenytoin (Dilantin)
o Atypical antipsychotics (clozapine)
Results from Other conditions such as
o Schizophrenia
o Cushing’s syndrome
o Hyperthyroidism
o Parenteral nutrition
Usually resolves when underlying condition treated
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MODULE 2
Diabetes Risk Factors
Diabetes Type
Risk Factors
Type 1
IDDM
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Autoimmune destruction
Family history
Type 2
NIDDM
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Obesity - cells become resistant to insulin
Family history
Inactivity
Race - Blacks, Hispanics, Aboriginal, South Asian, or Asian.
Age - above 4o years
Prediabetes - left untreated
Gestational diabetes - baby weighing more than 9 pounds at
birth
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Type 1 Diabetes – Clinical Manifestations
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Classic symptoms
o Polyuria (frequent urination)
o Polydipsia (excessive thirst)
o Polyphagia (excessive hunger)
Weight loss
Weakness
Fatigue
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Type 2 Diabetes – Clinical Manifestations
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Nonspecific symptoms
o May have classic symptoms of type 1
Fatigue
Recurrent infection
Recurrent vaginal yeast or monilia infection
Prolonged wound healing
Visual changes
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MODULE 2
Quick Check
The nurse is caring for a client admitted with type 2 diabetes who asks
the nurse what "type 2" means. Which of the following statements is the
best response by the nurse?
A) "With type 2 diabetes, the body of the pancreas becomes inflamed."
B) "With type 2 diabetes, insulin secretion is decreased, and insulin
resistance is increased."
C) "With type 2 diabetes, the client is totally dependent on an outside
source of insulin."
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D) "With type 2 diabetes, the body produces autoantibodies that destroy
B-cells in the pancreas."
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MODULE 2
Diabetes – Manifestations
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Diabetes – Diagnostic Tests
Tests
Findings
Urine analysis
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Presence of glucose and ketones from the breakdown of fat
Fasting blood glucose
(FBS) level
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> 7.0 mmol/L on two occasions
Levels between 6.1 mmol/L and 7.0 mmol/L are referred to as
impaired fasting glucose or prediabetes
Hemoglobin A1c test
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Used as another option for diagnosing diabetes and identifying
prediabetes (pre-diabetes = 6 - 6.4% and diabetes = >6.5%)
Oral glucose tolerance test
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> 11.0 mmol/L after 2 hours when a glucose load of 75 g is used,
plus classic symptoms
Random (non-fasting)
blood glucose test
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> 11.0 mmol/L and accompanied by increased thirst, urination and
fatigue, diabetes is suspected
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MODULE 2
Quick Check
The nurse is caring for a 54–year–old client who is hospitalized with
diabetes mellitus. Which of the following laboratory test results would
provide information related to the client's past glucose control?
A) Prealbumin level
B) Urine ketone level
C) Fasting glucose level
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D) Glycosylated hemoglobin level
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MODULE 2
Diabetes - Management
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MODULE 2
Diabetes – Collaborative Care
Goals of diabetes management
 Decrease symptoms
 Promote well-being
 Prevent acute complications
 Delay onset and progression of long-term
complications
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MODULE 2
Diabetes – Nutritional Therapy
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Cornerstone of care for person with diabetes
Most challenging for many people
Diabetes nurse educator and registered dietitian with diabetes
experience should be members of care team
Canadian Diabetes Association (CDA)
o Provides a variety of nutrition teaching tools to assist health
care providers
o Available through CDA office or website
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MODULE 2
Diabetes – Nutritional Therapy
Type 1 diabetes mellitus
 Meal plan is based on individual’s usual food intake and is
balanced with insulin and exercise patterns
 Insulin regimen is managed day to day
Type 2 diabetes mellitus
 Emphasis is based on achieving glucose, lipid, and blood pressure
goals
 Calorie reduction
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MODULE 2
Diabetes – Nutritional Therapy
Meal Planning:
 Food guidelines
o Caloric requirements and distribution: Nutritional energy
intake should be balanced with energy output
o Carbohydrates, fat, vegetables, fibre
o Eating out plan (PLANAHEAD - see notes below slide)
o Carbohydrate counting
 Consistency and timing of meals
 Review diet history
o Need for weight loss or maintenance
 Other dietary considerations
o Alcohol, sweeteners, reading labels
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Diabetes – Nutritional Therapy
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Carbohydrates
o Sugars, starches, and fibre
o Carbohydrate allowance: less than 10% of daily energy should come from
sucrose (sugar)
Glycemic index (GI)
o Term used to describe rise in blood glucose levels after carbohydrate-containing
food is consumed
o Should be considered when a meal plan is formulated
Fats
o Reduce combined saturated fats and trans-fats to less than 7% of energy intake.
Include foods rich in polyunsaturated omega-3 fatty acids and plant oils
Alcohol
o High in calories
o No nutritional value
o Promotes hypertriglyceridemia
o Detrimental effects on liver
o Can cause severe hypoglycemia
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Diabetes - Exercise
Importance
 Lowers blood sugar and cardiovascular risk, reduces weight
o Increase insulin receptor sites
Precautions
 Eat a 15g carbohydrate snack before moderate exercise
o Prevent hypoglycemia
 Adjust insulin regimen
o If exercising to control or reduce weight
 Monitor blood glucose levels before and after exercise
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Diabetes - Exercise
Recommendations
 Regular daily exercise
 Best done after meals
 Gradual increase in exercise
 Modify exercise regimen
 Monitor blood glucose levels before, during, and after exercise
 Exercise stress test for patients older than age 30
 Gerontological considerations
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Diabetes – Blood Glucose Monitoring
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Self-monitoring, (Ongoing) measurement of blood sugar level
Done using glucometer
Client training is crucial
Important for detecting hyper/hypoglycemia
Before meals - 3.9 to 7.2 mmol/ L
After meals - < 10 mmol/ L
Values vary depending on physical activity, meals and insulin
administration
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MODULE 2
Diabetes - Medications
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Oral antidiabetic drug
o Metformin
Insulin therapy
o Insulin from an outside source
o Required for type 1 diabetes
o Prescribed for client with type 2 diabetes who cannot control
blood glucose by other means
o Subcutaneous or intravenous
o Rapid acting, short acting, intermediate-acting, very longacting; can be used in combination.
Recall: Diabetes
Medications are
discussed in detail
in your
pharmacology
course!
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MODULE 2
Diabetes – Education
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Nutrition
Exercise
Blood glucose monitoring
Medication or insulin use
Foot care
Sick-Day management
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MODULE 2
Quick Check
The nurse is caring for a client diagnosed with type 2 diabetes. In
formulating a teaching plan that encourages the client to actively participate
in management of the diabetes, which of the following actions should the
nurse do first?
A) Assess client's perception of what it means to have diabetes.
B) Ask the client to write down current knowledge about diabetes.
C) Set goals for the client to actively participate in managing his
diabetes.
D) Assume responsibility for all of the client's care to decrease stress
level.
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MODULE 2
Diabetic Foot Care Guidelines
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Inspect feet daily
Wash feet in lukewarm (not hot) water
Moisturize feet but not between toes
Cut nails carefully
Never treat corns or calluses
Proper shoes and socks
No smoking – maintain peripheral circulation
Protect feet from hot and cold
Activity and nutrition
Regular visits to doctor (Chiropodist) - foot exams
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Diabetic Foot Care
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Conditions of the feet that require follow-up with a doctor or
diabetic foot care specialist:
o Corns and calluses
o Fungal infection of the nails
o Ingrown toenails
o Tinea Pedis (Athlete’s foot)
o Plantar warts
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Diabetes – Education
Sick-day Guidelines:
 Never omit insulin dosage
o Take the usual dosage of insulin
o Keep regular insulin on hand for supplemental doses as
prescribed by doctor
 Monitor blood glucose and urine ketones every 2-4 hours
o Whenever blood glucose is >13.3 mmol/ L, test urine for
ketones and record all results
 Drink plenty of fluids
o If unable to eat, drink fruit juices
 Contact doctor or NP if illness becomes severe or unmanageable
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Diabetes – Special Considerations
Children and Adolescents - parent’s role - diet restrictions, activity levels and
compliance with instructions
Pregnant Women - healthy lifestyle to reduce the risk of type 2 diabetes - balanced
diet, regular exercise and weight maintenance
Elderly - children’s role - ensure parent is eating well, encourage regular physical
activity, check parent’s feet regularly, learn signs of hypoglycemia
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MODULE 2
Quick Check
A school-age child with type 1 diabetes mellitus has soccer practice
three afternoons a week. The nurse reinforces instructions regarding
how to prevent hypoglycemia during practice. The nurse tells the child
to:
A) Drink a half a cup of orange juice before soccer practice
B) Eat twice the amount that is normally eaten at lunchtime
C) Take half of the amount of prescribed insulin on practice days
D) Take the prescribed insulin at noontime rather than in the
morning
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MODULE 2
Diabetes – Acute Complications
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Hypoglycemia
Diabetic Ketoacidosis (DKA)
Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
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Acute Complications – Hypoglycemia
Abnormally low blood glucose level (<4 mmol/L)
Causes - too much insulin in proportion to glucose in the blood, or oral
hypoglycemic drugs, too little food and excessive physical activity
Manifestations - cold sweats, tremors, tachycardia, pallor, palpitations,
nervousness and hunger, inability to concentrate, headache, confusion,
slurred speech, irritability, double vision and drowsiness, seizure or coma
At the first sign
 Check blood glucose
o If <4 mmol/L, begin treatment
o If >4 mmol/L, investigate further for cause of signs/symptoms
o If monitoring equipment not available, treatment should be initiated
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Hypoglycemia Management
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Administer 15 g - 20 g of simple carbohydrates
o 3 or 4 glucose tablets, 1/2 cup (4 ounces) fruit juice or regular,
non-diet soda, 6 to 10 hard candies, 1 tablespoon sugar (plain
or dissolved in water), 1 tablespoon honey or syrup
 Retest blood glucose in 15 minutes
o Treat again if <3.8 to 4.0 mmol/L or if symptoms persist
 Provide a snack with protein and carbohydrate unless the patient
plans to eat a meal within 30 to 60 minutes
Emergency Measures:
 If patient cannot swallow or is unconscious (insulin shock):
o Subcutaneous or intramuscular glucagon 1 mg
o In acute care settings: 25 to 50 mL 50% dextrose solution IV
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MODULE 2
Diabetic Ketoacidosis (DKA)
 Occurs when body is unable to use glucose
 Caused by profound deficiency of insulin
 Body has not enough insulin
 Breaks down fat as alternative source of fuel
 By-products of fat breakdown, called ketones, build up in the body
 Usually occurs with type 1 diabetes
 Blood glucose level is usually > 16.6 mmol/L
Precipitating factors:
 Illness
 Infection
 Inadequate insulin dosage
 Undiagnosed type 1 diabetes
 Poor self-management
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Diabetic Ketoacidosis (DKA)
Clinical features - Early symptoms (lethargy/weakness),
hyperglycemia, dehydration, acidosis
Manifestations - polyuria, polydipsia, abdominal pain, nausea,
vomiting, acetone breath, Kussmaul’s respiration: rapid deep
breathing & sweet fruity odour
Management:
 Airway Management - O2 administration
 IV fluids - replace losses from osmotic diuresis, vomiting
 IV insulin drip - regular insulin infused only to increase glucose
utilization
 Electrolyte replacement - sodium or potassium based on lab
results
 Monitor - blood glucose, vital signs, ECG (decreased K+ level)
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MODULE 2
Quick Check
The nurse is caring for a client with diabetes mellitus who has a
glucose level of 21.1 mmol/L and a moderate level of ketones in the
urine. As the nurse assesses for signs of ketoacidosis, which of the
following respiratory patterns would the nurse expect to find?
A) Central apnea
B) Hypoventilation
C) Kussmaul's respirations
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D) Cheyne-Stokes respirations
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Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
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A complication of type 2 diabetes, less common than DKA
Involves extremely high blood sugar (glucose) levels without the presence of
ketones
 Life-threatening syndrome
 Causes - not taking diabetic medications and not drinking enough fluids
 Manifestations - dehydration, confusion, increased thirst, dry mouth,
increased urination (at the onset of the syndrome), nausea, lethargy,
weakness, weight loss
Usually history of:
 Inadequate fluid intake
 Increasing mental depression
 Polyuria
Laboratory values
 Blood glucose >34 mmol/L
 Increase in serum osmolality
 Absent/minimal ketone bodies
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Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
Management:
 Client has enough circulating insulin that ketoacidosis does not
occur
 Produces fewer symptoms in earlier stages
 Correct fluids and electrolytes imbalances with IV fluids
 Therapy is similar to DKA
 Administer insulin
 Requires greater fluid replacement than DKA
 Monitor fluid volume and electrolytes status
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Chronic Complications of DM
Diabetic Retinopathy – Process of microvascular damage to the blood vessels in
the retina as a result of hyperglycemia, presence of nephropathy, and
hypertension.
Diabetic Nephropathy – Microvascular complication associated with damage to
the small blood vessels that supply the glomeruli of the kidney. It is the
leading cause of end-stage renal disease in Canada.
Diabetic Neuropathy – Nerve damage that occurs because of the metabolic
derangements associated with the disease. Sensory neuropathy is a major
risk factor for lower extremity amputation in the person with DM.
Complication of the foot and lower extremities – Complications result from a
combination of microvascular and macrovascular diseases that place the
patient at risk for injury and serious infection that may lead to amputation.
Integumentary complications – Skin is often affected in those with DM.
Acanthosis nigricans is a dark, coarse, thickened skin pigmentation.
Infection – Patients with DM are more susceptible to infection. This is due to the
mobilization of inflammatory cells and an impairment of phagocytosis by
neutrophils and monocytes. Organisms such as yeast thrive in high-blood
glucose environments.
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MODULE 2
In Summary
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CRITICAL THINKING CASE STUDY
Module 2
Please open the critical thinking case study on
SLATE:
‘Module 2 Case Study’
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MODULE 2
References:
Elaine N. Marieb (2012). Essentials of Human Anatomy and Physiology. San Francisco: Pearson Education
Inc., Benjamin Cummings
Day, R.A., Paul, P., Williams, B., Smeltzer, S.C., Bare, B.. Brunner and Suddarth's Textbook of Canadian
Medical-Surgical Nursing (Current Edition). Philadelphia: Lippincott Williams & Wilkins
Kwong, J., Reinisch, C., Tyerman, J., Cobbett, S., Hagler, D., Harding, M., & Dott (2023). Lewis's Medical-Surgical Nursing in
Canada (5th Edition). Elsevier Health Sciences (US).
Lewis, S.L., Bucher, L., Heitkemper, M.M., Harding, M.M., Barry, M.A., Lok, J., Tyerman, J., Goldsworthy, S.
(2019). Medical-Surgical Nursing in Canada (4th ed.). CA: Elsevier
http://orlandoprimarycarephysicians.com/blog/diabetes-mellitus-an-epidemic-today/
http://goeshealth.com/family-health/characterizing-children-diabetes-mellitus.html/attachment/diabetesmellitus-type-1
http://www.vitamindcouncil.org/health-conditions/type-ii-diabetes/
http://www.healthcentral.com/diabetes/h/gestational-diabetes-and-headaches.html
http://www.essentialoilspedia.com/diabetes/
http://guardianlv.com/2013/06/diabetes-mellitus-avandia-drug-raises-heart-attack-risk/
http://chilliyes.com/2013/08/24/you-need-to-know-4-types-of-diabetes-mellitus/
http://diabetestrustfoundation.org/medications-for-type-ii-diabetes.php
http://www.healingfeet.com/blog/foot-care/corns-on-the-feet-not-on-the-cob
http://www.beautybulletin.com/hands-feet/foot-care/foot-care-home-remedies-for-the-most-common-footailments
http://www.ourhealthnetwork.com/conditions/FootandAnkle/AthletesFoot.asp
http://blog.sterishoe.com/diabetes/common-diabetes-foot-problems/
http://blogs.theprovince.com/2013/01/13/new-diabetes-drug/
http://abcmedicine2.blogspot.ca/2012/11/diabetes-mellitus.html
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