Table of Contents:
1. Pathophysiology & Assessment
2. Interventions & Teaching
3. Medications
4. Acute Complications
Diabetes Mellitus
1. Pathophysiology & Assessment
y Glucose can’t reach cells Cells starve +
glucose builds up in the blood
FIGURE 1. ‘3 Ps’ OF DIABETES
Endocrine
Diabetes mellitus = impaired glucose metabolism
Type 1 (T1DM):
y Autoimmune destruction of pancreatic
beta cells No insulin is produced.
y Onset before early adulthood, usually following a
stressor (infection, trauma)
Type 2 (T2DM):
y Chronic hyperglycemia overwhelms glucose
transporters in tissues Insulin resistance
y Insulin is produced, but tissues don’t respond
Glucose can’t enter cells.
#1 risk factor = obesity
Metabolic syndrome = increased risk for T2DM and
cardiovascular disease in clients with ≥3 of
the following:
y
y
y
y
y
Abdominal obesity
Hyperglycemia
HTN
triglycerides
HDL
Assessment findings:
y Hyperglycemia
y Weight loss
The 3 Ps (FIGURE 1):
y Polyuria: Excess urination (glucose spills into urine
osmotic diuresis)
y Polydipsia: Excess thirst (diuresis dehydration)
y Polyphagia: Excess hunger (cells are starving)
Signs of chronic vascular damage:
y
y
y
y
Frequent infections
Poor wound healing
Blurred vision (retinopathy)
Paresthesias (neuropathy)
2. Interventions & Teaching
Interventions for diabetes focus on 1) achieving glycemic
control through a combination of lifestyle modifications
and medications (See TABLE 4) and 2) teaching the client
to prevent complications.
First-line treatment = Diet, exercise, and weight loss
(+ insulin for T1DM).
y Glycemic control monitored with hemoglobin A1C.
A1C%: Represents average glucose levels for
past 3 months
y Diagnosed with DM if A1C ≥6.5%
y A1C treatment goal for DM ≤7.0%
Diet:
y Individualized for weight loss
y Choose fruits and vegetables instead of simple
(“empty”) carbohydrates (white bread,
sugary beverages).
y Carbohydrate counting may be required for clients
taking high-dose insulin.
The three classic signs of diabetes are polyuria, polydipsia, and polyphagia.
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Exercise:
y Improves glycemic control, supports weight loss,
andcardiovascular risk.
y Perform moderate activity (brisk walk) 150 min/week.
Monitor glucose before, during, and after exercise.
y Eat 1 hour before exercise (exercise when glucose
levels are peaking).
Clients should not exercise if they have ketonuria or
severe hyperglycemia (>200 mg/dL [>13.9 mmol/L]).
y During exercise, wear an identification bracelet and
carry a fast-acting carb source (see TABLE 2).
Teach client how to check glucose:
y Wash hands before and after.
y Follow manufacturer instructions for calibration and
strip expiration date.
Do not share or reuse lancets.
If results seem incorrect, check technique and strip
expiration, then repeat the measurement.
TABLE 1. SIGNS OF HYPO- AND HYPERGLYCEMIA
Hypoglycemia
Hyperglycemia
Cold and clammy?
Need some candy.
Hot and dry?
Sugar’s high.
y Confusion, irritability
y Tremor, diaphoresis
y Palpitations,
tachycardia
y If severe: Seizure,
coma, death
y Lethargy
y Hot, flushed, dry skin
y Polydipsia, polyphagia,
polyuria
y If severe (DKA): Fruity
breath
Hypoglycemia management:
y Hypoglycemia = more dangerous than
hyperglycemia (can cause permanent neuron
death, seizures).
If no glucose meter is available to discern hypervs. hypo-glycemia, assume the client
has hypoglycemia.
Check the blood sugar for any client with an acute
change in mental status.
y Treatment follows the “Rule of 15”: 15 grams of
carbohydrate + recheck glucose in 15 minutes:
Endocrine
2. Interventions & Teaching, Continued
TABLE 2. HYPOGLYCEMIA TREATMENT
Is the client alert enough to swallow?
Alert:
1. Give 15 grams of carbohydrate:
y ½ cup juice or non-diet soda
y 5 LifeSavers candies
y 1 tablespoon (15 mL) honey
y Glucose tabs or gel
2. Recheck in 15 minutes.
3. Repeat dose PRN.
4. After sugar stabilizes Give a snack with
carbs + protein (crackers + peanut butter).
Unconscious or confused:
1. Inject glucagon IM or 50% dextrose IV.
2. Turn to one side if giving glucagon (can
cause nausea).
3. Recheck in 15 minutes + repeat dose PRN.
4. Notify HCP.
DO NOT:
y Give fatty foods (ice cream, candy bar, whole
milk) because fat slows glucose absorption.
y Give large amounts of sugar (causes
hyperglycemia).
Tremor, diaphoresis, and acute change in
mental status are signs of hypoglycemia.
To treat hypoglycemia, give 15 grams of
carbohydrates if client is alert; inject glucagon
or dextrose if client is unresponsive. Recheck
the glucose in 15 minutes and repeat the
dose PRN.
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2. Interventions & Teaching, Continued
Teach the importance of glycemic control to prevent
complications of widespread vascular damage:
TABLE 4. ORAL DIABETES MEDICATIONS AT A GLANCE
y Atherosclerosis (MI, stroke)
y Poor wound healing
Medications
Mechanism &
Considerations
Clients with diabetes need tight glucose control
after surgery.
risk for infection
y Retinopathy
Biguanides:
glucose output from liver
y Meticulous foot care to prevent diabetic foot
wounds
TABLE 3. DIABETIC FOOT CARE
y Inspect feet daily with a mirror.
y Dry feet thoroughly. No soaking the feet in water or
lotion between toes.
y Wear well-fitted, closed-toed shoes. No bare feet,
tight shoes, or open-toed shoes (flip-flops).
y Cut toenails straight across.
y No heating pads.
3. Medications
Insulin and/or oral diabetes medications:
y Insulin: Always indicated in T1DM and may be indicated
in T2DM if severe
y Oral diabetes medications: Only effective in T2DM
(because insulin is still produced)
Oral diabetes medications:
y glucose using various mechanisms (insulin secretion
from pancreas,glucose output from liver).
y Multiple classes are often given in combination to
achieve A1C <7.0%.
First-line for T2DM
Hold for 48 hours
before IV contrast to
prevent lactic acidosis.
Endocrine
Need annual eye exam for screening by an
ophthalmologist
y Nephropathy
y Peripheral neuropathy
metformin
Incretins:
GLP-1 (glucagon-like
peptide) agonists:
dulaglutide
semaglutide
DPP-4 (dipeptidyl
peptidase 4) inhibitors:
sitagliptin
saxagliptin
SGLT-2 (sodiumglucose
cotransporter-2)
inhibitors:
dapagliflozin
empagliflozin
Sulfonylureas:
glipizide
glimepiride
glyburide
glucagon secretion,
slow gastric emptying, and
aid in weight loss
y Can cause pancreatitis;
report jaundice or
abdominal pain.
glucose excretion into
urine
y risk for vaginal and
urinary tract infections
insulin secretion from
pancreas
Hold if NPO; can cause
hypoglycemia.
y Avoid alcohol
(disulfiram-like reaction).
Clients with diabetes should inspect feet daily with a mirror; keep feet clean and dry; and wear
well-fitted, closed-toed shoes.
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3. Medications, continued
Endocrine
FIGURE 2. INSULIN TIMING
Insulin:
y Enables glucose and potassium (K+) to enter cells
Client should start eating before the insulin onset
(e.g., within 15 min of lispro dose) (FIGURE 2).
FIGURE 3. DKA PATHOPHYSIOLOGY
Other medication considerations:
Steroidsblood sugar.
Beta blockers can cause hypoglycemic unawareness.
4. Acute Complications
Diabetic ketoacidosis (DKA)
y Life-threatening state of severe insulin deficiency
y Often precipitated by infection or other stressor
To prevent DKA, clients with DM who are sick
shouldfluid intake and monitor their blood
sugar and urine ketones, even if not eating.
y Pathophysiology:
y Glucose builds up in blood (hyperglycemia)
Osmotic diuresis Dehydration
y Body metabolizes fat and protein Buildup
of ketone bodies, acidic byproducts of fat
breakdown Ketosis (metabolic acidosis)
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4. Acute Complications, Continued
y Assessment findings:
Hyperosmolar hyperglycemia syndrome (HHS)
y Nausea, vomiting
y Severe dehydration
y Lethargy, coma
Deep, rapid respirations (Kussmaul respirations)
y Compensation for acidosis (“blows off”
acidic CO2)
y Lab findings:
y Occurs in T2DM, where enough circulating insulin is
present to prevent DKA
y Findings similar to DKA, except:
Endocrine
y Severe hyperglycemia (>300 mg/dL [16.7
mmol/L])
y Hyperkalemia (K+ needs insulin to enter cells)
y Metabolic acidosis (pH and HCO3)
y Ketonuria
Initial interventions:
y No ketosis (negative ketones, normal ABG)
y More severe hyperglycemia (>800 mg/dL
[>44.5 mmol/L])
y Treatment is similar to DKA (IV fluids, IV insulin,
electrolyte replacement).
1. Give IV fluids to treat dehydration (#1 priority).
2. Give IV regular insulin to treat hyperglycemia
and hyperkalemia.
y Rapid drop in glucose can pull water into the
brain ICP
y During IV insulin infusion, frequently
monitor mental status, glucose, and
potassium (K+).
y Ongoing interventions:
y Frequently monitor:
y Perfusion status (VS and UOP)
y Mental status (forICP)
ECG (for dysrhythmias from K+ shifts)
y Check glucose hourly.
Once glucose falls ≤250 mg/dL
(13.8 mmol/L), switch to IV fluids with
dextrose (D5NS).
y Give potassium (K+) replacement PRN.
y Give IV sodium bicarbonate for severe acidosis
(pH <7).
The two priority medications to treat DKA are IV fluids and insulin. During an IV insulin infusion,
monitor potassium and glucose levels and for signs of increased ICP.
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Tremor, diaphoresis, and acute change in mental
status are signs of ____glycemia.
To treat hypoglycemia in an alert client, give
___ grams of carbohydrates and recheck the
blood sugar in __ mins. What if the client is
unconscious?
Clients with diabetes should inspect their feet
_____ (how often?) and wear well-fitted,
_______-toed shoes.
The two priority medications to treat DKA are
IV _____ and IV _____. During DKA treatment,
monitor _____ (which 2 lab values?) and for
signs of increased _____.
Answers: 1. polydipsia, polyuria, polyphagia 2. hypoglycemia 3. 15, 15; turn to one side and inject glucagon or dextrose 4. daily, closed
5. IV insulin, IV fluids, glucose and potassium, ICP
References:
Attributions:
Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (Eds.).
(2023). Lewis’s medical-surgical nursing: Assessment and
management of clinical problems (12th ed.). Elsevier.
Insulin timing: Created with BioRender.com
Ignatavicius, D., Heimgartner, N., & Rebar, C. (Eds.). (2024).
Medical-surgical nursing: Concepts for clinical judgment
and collaborative care (11th ed.). Elsevier.
Tyerman, J., Cobbett, S., Harding, M. M., Kwong, J., Roberts, D.,
Hagler, D., Reinisch, C. (Eds.). (2023). Lewis’s medicalsurgical nursing in Canada: Assessment and management
of clinical problems (5th ed.). Elsevier.
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Endocrine
The three classic signs of diabetes are P_____,
P_____, and P_____.
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