DIABETES MELLITUS
STATE UNIVERSITY OF NEW YORK AT
STONY BROOK
1 YEAR NURSING PROGRAM
SUMMER 2008 HNI 364
The story of patient S.S.
Who is S.S.?: Case History
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White female, 5’ tall, 87 lbs.
Active, thin 14 year-old
General good health, occasional cold/flu
Never been hospitalized
Family history: maternal grandmother has
hyperthyroidism
History of Present Illness
(HPI)
• Late fall, Mrs. S. noticed that S.S. was pale and
less active
• S.S. felt tired and began to avoid friends and
activities (wanted to resign from cheerleading!)
• S.S. was constantly hungry, but still thin.
• S.S. noticed she had to use the bathroom after
almost every class.
• S.S. was irritable, had difficulty concentrating
• Due to these symptoms, Mrs. S. took S.S. to
family physicians
S.S.’s current status
• S.S. has lost 7 lbs in last week, despite eating 56 meals /day.
• Skin is pale and dry
• VS are within normal limits, but respirations and
ulse rates are higher than on previous physical
exams.
• Voiding lg. amounts of urine q 1-2 hrs
• Constantly hungry, thirsty, fatigued
• Fasting glucose level = 396 mg/dl
• Urine acetone +
S.S. is diagnosed with Type 1 diabetes
and hospitalized to regulate her insulin!
Conclusions
• S.S. and her family
demonstrated technical
competence and
understanding in:
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Blood glucose monitoring
Urine testing
Diet activity
Sick day management
Reason for urine testing
S.S. released from hospital!!
Question 1A:
What was the most likely
cause of S.S.’s polyuria
and weight loss before
her hospitalization?
Diabetes Type 1
No insulin formed
by pancreas
No uptake of glucose
by body’s cells
Accumulation of glucose
in bloodstream
(Hyperglycemia)
Increased solute concentration in
blood due to excess glucose
H20 moves from high
to low solute concentration:
from cells to intravascular space
Body excretes excess
H20, glucose, and
electrolytes in urine
Cell dehydration
Why did S.S. lose
weight?
When your body
cannot utilize
glucose for energy it
will begin to
breakdown adipose
tissue or fat and use
that for energy,
which explains the
weight loss.
Question 1B:
What are normal blood
glucose levels?
Normal blood glucose
• Normal blood glucose levels, before
meals, should be less than 100 mg/l.
• Normal blood glucose levels, 2 hours after
meals, should be less than 140 mg/l.
• Realistic target levels for people on
medication is 70 – 140 before meals and
less than 180 after meals.
Question 2:
Compare and contrast the signs
and symptoms of diabetic
ketoacidosis and insulin shock.
Explain why each occurs.
The DIFFERENCES
between
ketoacidosis
&
insulin shock
Lab tests
Ketoacidosis
• High blood glucose
levels (> 250 mg/dL)
• Accumulation of
ketones in urine and
blood
Insulin shock
• Low blood glucose
levels (< 45 mg/dL)
Symptoms
Ketoacidosis
Extreme thirst
Dehydration
Dry mouth
Frequent urination
Fatigue
Nausea/Vomiting
Difficulty breathing
Difficulty concentrating
Insulin shock
Confusion
Difficulty concentrating
Irritability
Weakness
Tremors
Anxiety
Hunger
What’s the deal with
ketoacidosis?
• When the body cannot use glucose for energy
due to the lack of insulin, the glucose is
converted into fat for energy.
• Excess fat is broken down by the liver and
produces ketone bodies, which end up in the
urine (ketouria).
• Polyuria further increases the concentration of
ketone bodies in the urine.
• Breakdown of protein in the body also produces
ketone bodies, contributing to ketoacidosis.
What causes insulin shock?
• Too much insulin in the
blood due to overdose
during an insulin shot.
• Since insulin is
responsible for uptake of
glucose into body’s cells,
too much insulin results in
too little blood glucose.
• Immediate intake of sugar
will counteract insulin
shock.
Similarities between
ketoacidosis & insulin shock
• Both ketoacidosis and insulin shock are
severe, emergency situations.
• If left unaddressed they can both lead to
coma.
• The best way to prevent either one is to
constantly monitor blood glucose levels.
Question 3: Why must insulin be
injected? Discuss the various types of
insulin, their time of onset, peak of action
and duration of action. Do persons with
Type II diabetes ever require insulin
injections? If so, when and why?
Why must insulin be injected?
• Insulin is a protein made up of two peptide chains
linked together by disulfide bonds.
• Proteins are broken down and digested by proteases
(i.e. pepsin in the stomach & trypsin in the small
intestines)
• If taken orally, insulin will therefore be broken down
and deactivated, never reaching the blood stream
• Insulin must be injected SQ to provide a more direct
route of entry into the blood stream
Types of Insulin
• Rapid (Quick-acting)
-Insulin Lispro
• Short Acting
-Regular (R)
• Intermediate-Acting
-NPH (N) or Lente (L)
• Long-Acting
-Ultralente (U)
• Pre-mixed
Rapid Insulin
• Onset: 5-15 minutes
• Peak of Action: 1 hour after injection
• Duration of Action: 3-4 hours
Short-Acting (Regular) Insulin
• Onset: 30-45 minutes
• Peak of Action: 2-3 hours after injection
• Duration of Action: 5-8 hours
Intermediate-Acting Insulin
• Onset: 2-4 hours
• Peak of Action: 4-10 hours after injection
• Duration of Action: 10-16 hours
Long-acting Insulin
• Onset: 6-10 hours
• Peak of Action: has a peak, but top speed
looks like its normal speed
• Duration of Action: 20 + hours
Pre-mixed Insulin
• Onset: 30 minutes
• Duration: 16-24 hours
Figure 2. Onset of action, peak, and duration of action of exogenous insulin
preparations. (Neutral protamine Hagedorn = NPH)
Reprinted with permission from the American Diabetes Association's Clinical Education Program
"Insulin Therapy for the 21st Century."
Do persons with Type II Diabetes ever
require insulin injections? If so, when &
why?
• Type II diabetes occurs when the body produces
enough insulin, but the ability to process & use
this insulin is lost (the body becomes resistant)
Type II Diabetes Insulin
Requirements
• Injections of insulin should mimic normal
release patterns of the body
• Long-acting insulin is usually injected 1-2x a
day
• In addition, short-acting or rapid-acting insulin
is injected at mealtimes
Question #4
Goal for a nutrition program for
children with Type 1 Diabetes
• Maintain blood glucose levels without
causing excessive hypoglycemia
• When hypoglycemia occurs bring levels up
to 80 mg/dl
• Foods low on glycemic index do not
produce drastic changes in blood glucose
levels; i.e. whole grains, oranges and
peanuts
• DIET:
- > 50% calories from carbohydrates (1300
kcal/day)
- 10-15% calories from protein (260-390
kcal/day)
- 30-35% calories from fats (780-910
kcal/day)
Tips to help when eating out
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keep a count of calorie intake
eat slowly
eat same portions as you would at home
order foods that are not breaded or fried
choose healthy alternatives
carry diabetes kit with you.
if rapid acting insulin is taken, try to delay
injection until meal is served
• talk to doctor about how to adjust insulin
regimen when eating out
#5A How do you
prepare the injection?
Why?
•NPH (intermediate-acting) and regular
(shortacting) are commonly mixed to produce
differently-timed pharmacologic actions with a
single injection.
•The regular insulin is prepared
first to prevent it from becoming
contaminated with the
intermediate-acting insulin (NPH).
Steps To Preparing Injection
•Check the patient's name,
medication, dosage, route and time
of administration.
•Carefully verify insulin labels.
•Roll the NPH vial between hands to
resuspend the insulin preparation.
•If vial did not have cap on top, wipe
off with an alcohol swab.
•Verify dosage a second time.
Steps To Preparing Injection (Cont.)
• Take insulin syringe and aspirate volume of air equivalent
to the dose of insulin to be withdrawn from the
intermediate-acting (NPH) insulin first.
• DO NOT LET THE TIP OF NEEDLE TOUCH THE INSULIN.
• Remove syringe from vial without aspirating the insulin.
•With the same syringe
inject air equal to the dose
of insulin to be withdrawn
from the short-acting
(regular) insulin.
Steps To Preparing
Injection (Cont.)
• Withdraw the correct dose into the syringe (10 units of
regular). Verify again that the correct dose has been
withdrawn.
• Place the needle of the syringe back into the NPH vial and
withdraw the correct dose (10 units). Verify that the correct
dose has been withdrawn.
• The total amount of insulin in the syringe should be the sum of
the two types (20 units).
• Because short acting insulin was mixed with
intermediate-acting insulin, which reduces
the action of the faster-acting insulin, administer
the mixture within 5 minutes of preparation.
What Type of Syringe would
you use?
• A 50 or 100 unit Insulin syringe would be used
• Insulin is measured in units (check the insulin bottle)
* syringe measuring cc's or mL's cannot be used*
Since the total amount to
be given is 20 units, a low
dose 50 unit syringe is
appropriate, but a 100
unit syringe may also be
used.
What sites could you use for
the injection?
• Insulin should be
administered subcutaneously
• There are 4 main sites:
abdomen, posterior arms,
anterior and lateral thighs and
posterior hips
• The insulin is absorbed faster
in the abdomen and the rate
of absorption decreases in the
arms, thighs and hips
Education
• Teach the patient what treatments are used, how
the treatments work and how to administer the
drugs
• The patient should be aware of the effects of
continuously injecting into the same site
• They should know that it is important to rotate the
injection site
• They shouldn’t inject into a limb that is to be
exercised because it will be absorbed faster and
may result in hypoglycemia.
Question #5: Lipodystrophy and What are
some of the long term complications of diabetes and
why do they occur?
Researchers: J Strasheim & M. Valerio
Ppt. Preparer: Stefany Cimino
Presenter: Nancy Yang
Lipodystrophy: Localized Disturbance of
Fat Metabolism Below Skin Surface
Causes: Not Rotating Insulin Injection Sites
2 Forms:
1. Lipoatrophy
2. Lipohypertrophy
Lipoatrophy: Loss of Subcutaneous
Fat Under the Skin Surface Resulting in
Small Dents
• Appears as Slight Dimpling
• Appears as Pitting (more serious)
Lip hypertrophy: Buildup of Fat
Below the Skin Surface Causing lumps
• Appears as Fibro-Fatty Masses.
• Absorption is Delayed at these Sites.
• Avoid these Sites Until Hypertrophy
Disappears.
Question 5d:
• What are Some of the Long Term
Complications of Diabetes and Why Do
They Occur?
Diabetes: Long Term
Complications
• Affects the Metabolism of Every Cell in the
Body
• Adversely Affects the Body’s Blood Supply
• Can Lead to Life-Threatening and
Disabling Complications Over Time
• Therapeutic Management can Prevent or
Delay the Onset of Various Complications
3 General Categories of Long
Term Diabetes Complications
1. Macrovascular Disease
2. Microvascular Disease
3. Neuropathy
Macrovascular Disease
• Atherosclerotic Changes in Larger Blood
Vessels
• Diabetics are more Prone to Develop than
non-diabetics, but No clear-cut explanation
Why
• There is No Direct Link Between
Hyperglycemia and Artherosclerosis
• Diabetes is Seen as an Independent Risk
Factor
Macrovascular Examples
1. Coronary Artery
Disease (CAD)
2. Peripheral Vascular
Disease (PVD)
Coronary Artery Disease
• Artherosclerotic Changes in Coronary
Arteries
• Leads to MI and an Increased Chance of a
2nd MI
Peripheral Vascular Disease
• Atherosclerotic Changes in Large Blood
Vessels of Lower Extremities
• Decreased Peripheral Pulses
• Intermittent Claudication
• Increased Chance of Gangrene,
Amputation
Microvascular Disease
• Changes Unique to Diabetics
• Characterized by Capillary Basement
Membrane Thickening
• Increased Blood Glucose Levels React
through a Series of Biochemical
Responses to Thicken the Basement
Membrane
Microvascular Examples
1. Diabetic
Retinopathy
2. Neuropathy
Diabetic Retinopathy
• Changes in Small Blood Vessels in Retina
Neuropathy: Conditions Affecting
the Nerves
1. Renal Disease
2. Foot and Leg Problems
Renal Disease
• Diabetics comprise 25% of the patients
with End-Stage Renal Disease (ESRD)
requiring dialysis or transplantation
• Diabetics have a 20-40% chance of
developing Renal Disease
• Type I Diabetics show signs after 15-20
years
• Type II Diabetics show signs within 10
years of diagnosis
Renal Disease: After Onset
• The Kidney’s filtration
mechanism is stressed,
allowing blood proteins to leak
into urine
• Kidney Blood Vessel Pressure
Increases-thought to serve as
the stimulus for development
of Nephropathy
• As Renal failure progresses,
catabolism of insulin
decreases, and frequent
hypoglycemic episodes result,
requiring a change in insulin
DIABETIC NEPHROPATHY
Foot and Leg Problems
• 50-75% of all Lower Extremity
Amputations are performed on Diabetics
• Increased risk of foot infections
Three Contributing Factors
1. Neuropathy
2. PVD
3. Immunocompromised Status
Neuropathy
• Loss of pain and
pressure sensation,
increased dryness
and fissuring due to
decreased sweating
PVD
• Poor Circulation in
lower extremities,
causes poor wound
healing and increased
risk of gangrene
Immunocompromised Status
• Hyperglycemia
Impairs the ability of
specialized
Leukocytes to destroy
bacteria
• Decreased
Resistance to
Infections
Prevention
• Daily Foot Checks
What will you teach
Ms. S.S. regarding the
following situations she
may encounter ?
Question #6A.
Physical education
classes
and
cheerleading
practice
Physical education classes and
cheerleading practice
Exercise is an important part of any
diabetes treatment plan.
Exercise can actually increase your body’s
insulin sensitivity, which means your body
requires less insulin to guide sugar into
your cells.
Before and after physical
education/ cheerleading practice:
– Check glucose levels
100-200 mg /dL
You're good to go.
For most people, this is a safe pre-exercise
blood sugar range.
– Eat a healthy meal
– Hydrate yourself
Bring snacks and enough water or
Gatorade-type drinks to physical
education or cheerleading
If blood sugars are low try:
½ cup of juice or
few pieces of candy
If you feel lightheaded or dizzy
at any time
– Take a break
– Eat and drink
something to bring
up glucose levels
Always take breaks to hopefully avoid
feeling lightheaded, dehydrated or
dizzy
Check glucose levels after
30 minutes
if planning on exercising long
Wear cotton socks
Wear appropriate footwear
(i.e. no flip flops or sandals)
– You need support
and cushion
– Check feet daily,
especially plantar
surface (bottom of
foot)
What will you teach
Ms. S.S. regarding the
following situations she
may encounter:
Question 6B.
Illness e.g. colds and the flu,
episodes of diarrhea and
vomiting?
Diabetes management:
Creating
your
sick-day
plan
Diabetes management can
be especially challenging
when you're struggling
with a cold or other
illness.
Proper planning can help you
prevent complications.
You don't feel well.
Your temperature is
high, you're tired and
you've lost your
appetite.
Having diabetes only
adds to your
concerns.
 When you're sick, your body
produces hormones to help fight the
illness.
 These hormones raise your blood
sugar by preventing insulin from
working effectively.
 In people without diabetes, the
additional sugar promotes healing.
 But when you have diabetes, the
fluctuations can result in potentially
serious diabetes complications.
To prevent complications,
make a sick-day plan
part of your diabetes
management.
Start with your health care team
Talk to your doctor and other members of your diabetes
care team about your sick-day plan.
Make sure your sick-day plan includes:
What medications to take
 How often to measure your blood sugar and
urine ketones
 How to adjust your insulin dosage, if you need
insulin
 How to manage any other conditions you may
have
 When to call your doctor
Also identify a loved one or friend who can contact your
doctor or help you seek emergency care if you
experience diabetes complications.
Keep close track of your blood
sugar and urine ketone levels:
 Continue taking your diabetes medication when
you're sick, and remember to test your blood
sugar often. You may need to adjust your insulin
doses or other medications. Here are some
general guidelines:
 Type 1 diabetes. Check your blood sugar and
urine ketone levels every four hours.
 Excessively high blood sugar can lead to
ketoacidosis, especially in people who have type
1 diabetes. e conditions can be fatal.
Excessively high blood sugar
can lead to ketoacidosis,
especially in people who have
type 1 diabetes.
These conditions can be fatal.
Stick to your diabetes meal plan
With a minor illness such as a cold, you
may be able to stick to your diabetes
meal plan — which will help ensure
blood sugar stability. Remember to
check the sugar content of any overthe-counter medications you take.
Many cough syrups and other liquid
cold preparations are high in sugar.
If you have nausea, vomiting or diarrhea, you may
not be able to eat your regular foods. But it's still
important to get enough carbohydrates. Try these
foods, which contain about 10 to 15 grams of
carbohydrates each:
1 double-stick frozen fruit pop
 1 cup milk
 1/2 cup fruit juice
 1/2 cup regular (not diet) soda
 6 saltine crackers
 3 graham crackers
 1 slice dry toast
 1/2 cup regular (not artificially sweetened) gelatin
In addition to sipping fruit juice or
sweetened beverages, drink at least 8
ounces of water or other calorie-free liquid
every hour you're awake.
If you're not able to keep anything down,
it's especially important to monitor your
blood sugar closely.
Know when to contact your
doctor
Diabetes complications can quickly become dangerous.
Contact your doctor if:
 Your blood sugar level is higher than 300 mg/dL
 Your blood sugar level is higher than 240 mg/dL for more than 24
hours
 Your urine ketone level is moderate to high
 You feel sleepier than usual or can't think clearly
 You're unable to keep fluids down or vomit for more than six hours
 You have diarrhea for more than six hours
 You feel confused and can't think clearly
 Your lips and tongue appear dry and cracked
Think prevention
High blood sugar can weaken your
immune system. This makes you
more likely to get a cold or the flu —
and more vulnerable to serious
effects of common illnesses. To
reduce the risk of getting sick, wash
your hands often and avoid crowds
during flu season.
Think prevention
Ask your doctor about
vaccination for flu
and
pneumococcal
pneumonia.
If you do get sick,
feel confident in your ability
to manage your diabetes by
following
your sick-day plan.
Infections
Respiratory Infections
People with diabetes face a higher risk for influenza and its
complications, including pneumonia, possibly because
the disorder neutralizes the effects of protective proteins
on the surface of the lungs. In fact, deaths among people
with diabetes increase by 5 - 15% during flu epidemics,
and they are six times more likely to be hospitalized with
complications from flu than non-diabetic patients who
have flu. Everyone with diabetes should have annual
influenza vaccinations and a vaccination against
pneumococcal pneumonia.
Infections
Urinary Tract Infections
Women with diabetes face a
significantly higher risk for urinary
tract infections, which are likely to be
more complicated and difficult to treat
than in the general population.
#6C Glycosylated
Hemoglobin testing
Introduction
• Hemoglobin on red blood cells combine
with blood glucose to make glycosylated
hemoglobin
• Red blood cells store glycosylated
hemoglobin slowly over their 120-day life
span
What is it?
• A laboratory test also known as the
Hemoglobin A1C
• Analyzes the concentration of glycosylated
hemoglobin within the body’s circulation
• Determines blood glucose levels
• High blood glucose levels
– Result in red blood cells storing large
amounts of glycosylated hemoglobin
• Normal or near normal blood glucose
levels
– Result in normal or near normal amounts of
glycosylated hemoglobin
Why is it important?
• High Glycosylated Hemoglobin puts you at
risk for:
– eye disease
– kidney disease
– nerve damage
– heart disease and stroke
*especially true if the glycosylated hemoglobin
remains high for a long period
How is the glycosylated
hemoglobin test used?
• Diagnostic tool used by doctors for
diabetic patients since 1976
• Offers a good estimate of disease
management over a 2 to 3 month period,
in contrast to other tests that give a
onetime snapshot
• Used in the routine monitoring of patients
with diabetes mellitus
• How well patient is responding to
treatment
– Low test values reduce risk for having
complications from diabetes mellitus
How is the test
performed?
• Venipuncture
• Some may feel moderate pain, or only a
prick or stinging sensation.
• Afterward, there may be some throbbing
Examples of glycosylated
hemoglobin
• A glycosylated hemoglobin level of 7% is
considered to be good
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6%
8%
10%
13%
Very Good
Not too bad
Not good
Dangerous
Benefits S.S. will derive
from having the test done
• safely monitor her blood glucose levels
• newly diagnosed pt’s may have to monitor
levels closely over several 2-3 week
periods
Disadvantages to using
this test
• Results require interpretation by a
physician with knowledge of person’s
clinical condition
• False high or low may result
– Some medical conditions such as
splenectomies falsely increase levels
Any Questions?
References
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Potter, P.A., & Perry, A.G. (2009). Fundamentals of Nursing (7th edition).
St. Louis, MO: Mosby, INC.
Smeltzer, S.C & Bare, B.G. (1996). Medical-Surgical Nursing (8th edition).
Philadelphia, PA: Lippincott-Raven Publishers.
McCance, Huether et al. Pathophysiology. 4th Edition.
Abraham , E.C., Schwartz, M.K., (1985) Glycosylated Hemoglobins –
Mehtods of Anmalysis and Clinical Applications..
http://www.fda.gov/diabetes/glucose.html
http://www.endocrinologist.com
http://healthlibrary.epnet.com
http://www.healthatoz.com
http://www.labtestsonline.org/understanding/analytes/a1c/test.html
http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm
http://www.mdconsult.com/
http://mayoclinic.com/
Question
Intorduction
.PPT Creator
Sharon Jaffin
Presenter
Renee Brown
1: Alexis Galetta
Kim Barressi
2:Nicole Cariello
Cynthia McCreight
Sharon Jaffin
Linda Rampil
3: Ron Casella
Natalie De Roche
4:Amar Singh
Christina DeRosa
Christina Barbuto
Emily Gerbert
Bridget Erwin
Jennifer Dixon
5: Jamie Strasheim
Marisol Valerio
1st ½ of Q#5
Christine Abrams
Kevin Budway
5: Jamie Strasheim
Marisol Valerio
2nd ½ of Q#5
Stef Cimino
Nancy Yang
6: Katrina Stephano
Karen Broomes-James
Melinda Torey
Q6 A&B
Ari Vigborn
Stefanie Florio
6: Katrina Stephano
Karen Broomes-James
Melinda Torey
Q #6 & Finalization of
.PPT
Marissa Gonzalez
Renee Brown
Game
Alex Nee
Marissa Lutzer
Ashley Taylor
Rose Massana