Advanced Theoretical
concepts in Nursing
Diabetes Mellitus Type-II
By
Talat Rashid
December 12, 2007
Objectives
• Define the disease in the case study
• Discuss the prevalence, significance of Diabetes
Mellitus type II.(DM II)
• Describe the etiology, normal and altered
pathology, and s/s of DM II
• Explain the prevention/complications of DM II
• Review the pharmacological manag. of DM II
• Discuss nursing management of DM II by
incorporating the appropriate theory.
Case study
 47 yrs old, father.
 Appeared in Diabetes consultant clinic on
29-11-07
 Presenting features (from last 04 months)
- Sense of heaviness over lower
abdomen
- Retention of urine
- Excessive urination (Polyuria)
- Excessive thirst
(Polydipsia)
- Excessive eating (Polyphagia)
- Becomes angry on minor issues
cont……
 Family Hx:
DM (-), HTN (+), Cardiac dis (+)
 Personal/social Hx:
Businessman, normal sleep, Appetite,
feels has lost wt from 01 yr., smoking
from last 10 yrs
Vitals
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B.P 125/80 mmHg
Pulse: 80/min (regular)
RR: 22/min (unlabored)
Wt 85 kg
Ht: 180 cm
Pain score: 1(on pain scale of 1-10)
Allergies: Not known
General appearance
• An adult man with average built walked in
comfortably into the CC (accompanied by his
wife) and sit on the chair with ease. Oriented to
time, place and person, has clear speech &
relevant talk but seems to have attention & eye
contact during history taking and gives
incomplete answers occasionally, looks
depressed. Is well groomed and hydrated.
Physical Examination
• Ht 180cm
• Wt 85kgs
• Body Mass Index (BMI)
BMI = Wt (kgs) / Ht (mxm)
= 85 kgs /1.8m x1.8m
= 85 / 3.24
= 26.23kgs/m2 (n.range= 19-24kgs/m2)
Overweight
Review of systems
Skin: inspection for breakdown, non healing pustules,
diabetic ulcer or wound, Diabetic foot.
Neurological system: Sensory & motor system. Paralysis, Balance,
response to pain & sensitization of hot or cold application over
limbs for parasthesia to rule out Diabetic Neuropathy,
Cognition status: orientation, alertness, memory status.
Eyes: vision, pain, cataracts, fundoscopy to rule out Diabetic
Retinopathy
Mouth: inspection of gums & teeth for infection, buccal mucosa for
sores,
Cont….
CVS: pain, palpitation, heart sounds, dysnea, murmurs,, HTN
PVS: varicose veins, thrombophlebitis, leg cramps
Genito-urinary : frequency of micturation, pressure symtoms,
burning
micturation, incontinence of urine, Diabetic Nephropathy
Musculoskeletal system : ROMs, strength, gait & balance
Endocrine : Goiter, change in weight, polyphagia, polidypsia,
polyuria, glycosuria
Differential Diagnosis
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Diabetes Mellitus Type II
Diabetes Mellitus Type I
Hyperlipidemia
UTI
BPH
Anxiety
Investigations
• FBS
134 mg/dl
• RBS
213 mg/dl
• Lipid Profile
T. Cholesterol 201 mg/dl (Nor < 250)
Triglycerides 104 mg/dl (Nor < 150)
HDL
40 mg/dl (Nor > 40)
LDL
143 mg/dl (Nor > 100)
• DIABETES MELLITUS TYPE II
(Non Insulin Dependant Diabetes
Mellitus)
Definition
• Type II diabetes is a chronic, common,
complex metabolic disorder characterized
by hyperglycemias, a disease of growing
public health concern
Significance
INCIDENCE
PREVENTABLE COMPLICATIONS
COMORBIDS
HOSPITAL / TERTIARY CARE
HOSPITAL WORKLOAD / NOSOCOMIAL INFECTIONS
NATIONAL ECONOMY
HEALTHY AND PRODUCTIVE COMMUNITY
Prevalence
• 2.9 million people globally died of diabetes
in 2000, about three times its previous
estimate.
WHO (2005)
• 200 million cases worldwide
(Report of a WHO Meeting, 2004 )
 Prevalence in United States
20.8 million (7 % population) had diabetes in 2005,
6.2 million of them undiagnosed. 90 to 95 % (18.7 million - 19.8
million people) of Diabetics had type 2 diabetes.
(U.S. National Institutes of Health-2006)
 Prevalence in Pakistan
The prevalence rate of diabetes 16.2% (9% known and 7.2% newly
diagnosed) in men and 11.7% (6.3% known and 5.3% newly
diagnosed) in women. The prevalence increased to almost 30% and
21% in 65-74 years old men and women respectively. 79% of
Diabetic men & 96% of Diabetic womenin Pakistan are obese.
(Javed, 2003)
Incidence
• Age
Traditionally thought to affect > 40 years
However, Incidence increasing in younger
persons, in prepubertal children,
teenagers, and young adults.
Type 2 diabetes mellitus is observed even
in some obese children.
• Sex; more common in women
Background
•
Unlike type 1 diabetes mellitus, patients are not
absolutely dependent upon insulin for life, even though
many of these patients are ultimately treated with insulin.
•
Many people do not realize that they are suffering
from type 2 diabetes as they experience symptoms of
fatigue, lethargy, extreme thirst, frequent urination,
susceptibility to infections and vision changes over a
prolonged period of time.
•
Being overweight can keep your body from making
and using insulin properly. It can also cause high blood
pressure
Endocrine system
• Endocrine glands
release hormones
(chemical messengers)
into the bloodstream to
be transported to
various organs and
tissues throughout the
body.The pancreas
secretes insulin, which
allows the body to
regulate levels of sugar
in the blood.
www.medline.medicine
Pancreas
• The pancreas is located
behind the liver and is
where the hormone
insulin is produced.
Insulin is used by the
body to store and utilize
glucose.
www.medline.medicine
Islets of Langerhans
• Islets of Langerhans
contain beta cells
and are located
within the pancreas.
Beta cells produce
insulin which is
needed to
metabolize glucose
within the body.
www.medline.medicine
Role of Insulin
Food intake
containing CHO
End product of CHO
metabolism GLUCOSE
Insulin is released
Glucose in the blood
Movement of glucose to
body’s muscle, fat & liver cells
Glucose used by the body
as FUEL for ENERGY
Path physiology
Production of Insulin (Auto immune)
Insulin resistance
by liver, fat & muscle cells
Ineffective movement of Glucose to the cell
no energy available to cells
Blood Levels of Glucose
Hyperglycemia
Etiology
• Presumably, the defects of type 2 diabetes mellitus
occur when a diabetogenic lifestyle (ie, excessive
calories a high-fat diet, inadequate caloric expenditure,
obesity) is superimposed upon a susceptible genotype
appears to cause type 2 diabetes mellitus.
• Diabetes mellitus may be caused by other conditions.
Secondary diabetes may occur in patients taking
glucocorticoids or when patients have conditions that
antagonize the actions of insulin (eg, Cushing syndrome,
acromegaly, pheochromocytoma).
Risk factors of DM
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A parent, brother, or sister with diabetes
Obesity
( fat cells become insulin resistant)
Age greater than 45 years
Gestational diabetes or delivering a baby
weighing more than 9 pounds
High blood pressure
High blood levels of triglycerides (a type of fat
molecule)
High blood cholesterol level
Not getting enough exercise
Cardinal characteristics of DM
• Hyperglycemia. Abnormally high glucose.
Left untreated
to coma or death.
• Hypoglycemia. Abnormally low glucose.
Left untreated
convulsions,
unconsciousness or brain damage.
COMPLICATIONS
Microvascular
 Diabetic Neuropathy eg; parasthesias and foot
problems
limb amputations
 Diabetic retinopathy eg; glaucoma, cataracts, macular
degeneration and blindness).
•
.
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Macrovascular
Coronary, peripheral- vascular, diabetic nephropathy
associated with BP & albumin in the urine (detected
by urinalysis) kidney failure
Others
Skin disorders and infections.
The stomach disorder
Sexual dysfunction..
Urinary incontinence
Gum disease
Arteriosclerosis of extremities
• Arteriosclerosis of the
extremities is a
disease of the blood
vessels characterized
by narrowing and
hardening of the
arteries that supply
the legs and feet. This
causes a decrease in
blood flow that can
injure nerves and
other tissues.
www.medline.medicine
Diabetic retinopathy
• Excessive amount
of glucose in the
blood stream may
cause damage to
the blood vessels.
Within the eye the
damaged vessels
may leak blood and
fluid into the
surrounding tissues
and cause vision
problems.
www.medline.medicine
Diabetic nephropathy
•
Uncontrolled diabetes
causes thickening and
hardening of the internal
kidney structures. A
kidney biopsy clearly
shows diabetic
nephropathy.
www.medline.medicine
Symptoms of DM II
• 3 Ps
Polydypsia (Increased thirst)
Polyuria
(Increased urination)
Polyphagia (Increased appetite)
• Fatigue
• Blurred vision
• Slow-healing infections
• Impotence in men
• Mood changes
• Sudden reduction in wt
Diagnostic criteria of DM II
•
The criteria adopted for the diagnosis of
diabetes & most commonly used is ‘The
American Diabetes Association (1997)’ :
1. Fasting plasma glucose (FPG) >126 mg/dL
on 2 occasions or random plasma glucose
(RPG) > 200 m g/dl
2. Classic symptoms of diabetes mellitus (ie,
polyuria, polydipsia, polyphagia, weight loss).
Cont…..
• Oral glucose tolerance test is +ive if
glucose level is >/= 200 mg/dL a/f 2 hrs of
intake.
• Hemoglobin A1c (HbA1c) level >7% is a
measure of average blood glucose during
the previous 2 to 3 months. It is a very
helpful way to determine how well
treatment is working.
• High triglycerides (>250 mg/dL) or low
HDL (<35 mg/dL).
Treatment of DM II
• Oral antidiabetics
*Tab Amaryl Img Bid
*Tab Glucobay 50mg BD
Tab Diabenese 100mg, 250mg
Tab Metformin 500mg OD
Tab Glucophage 500mg OD
Prophylactic drugs
*Tab Esso 40 mg OD
*Tab Ascard 70 mg OD
Tab Amaryl (Glymeperide)1,2&4mg
• Action unknown, glucose possibly by stimulating
release of insulin from functioning pancreatic
beta cells. May sensitivity of peripheral tissue to
insulin.
• Nsg considerations:
-Watch for hypoglycemia (cautiously used in
elderly & malnourished)
-Drug should be taken with first meal of the day
Tab Glucobay (Acarbose) 25,50
&100mg
• Alpha glycosidase inhibitor that delays
digestion of CHO, resulting in a smaller
rise in glucose level a/f meal
• Nsg considerations:
-Watch for hypoglycemia
-Contraindicated in inflammatory bowel
disease, colonic ulceration, predispositon
to intestinal obstruction.
Tab Ascard( Aspirin)70mg OD
Salicylate
•
Reduces risk of recurrent transient Ischemic attacks &
stroke in patients at risk, by impeding clotting by blocking
prostaglandin synthesis, which prevent formation of
platelet aggregation substance Thromboxone A2.
• Nsg considerations
- Use cautiously in pts with GI lesions, impaired renal
function, Vit k deficiency, bleeding disorders.
-Should be discontinued , if bleeding from any sight
occurs & 7 days prior surgery
- Pt taught to take drug with food
Cont…
Research in the proposed treatment of
type II diabetes :
 Replacement hormones, such as
glucagon-like peptide-1 (GLP-1).
 Pancreatic cell transplant, (the insulin
producing cells will be transferred to a
diabetic person to achieve a cure)
 Bariatric surgery
(Christine 2005)
Complications
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Heart attack
Stroke
Renal failure
Limb amputation
Prevention
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Exercise
Normal weight control.
Physical activity
Healthy diet
Strict blood glucose control
Integration of Theory in patient with DM
“Bandura’s Self-Efficacy Theory”
Model of triade resiprocality
Background of theory
• Self-Efficacy theory is an important
component of Bandura’s social cognitive
theory (1986), which suggests high interrelation b/w individual’s Behavior,
Environment and Personal ( cognitive,
affective, & biological events) factors.
(Graham & Winner, 1996)
Assumptions
• The reciprocal nature of the determinants of
human functioning in social cognitive theory
makes it possible for therapeutic & counseling
efforts to be directed at personal, environmental
or Behavioral factors.
• Hence strategies for well-being can be aimed at
improving emotional, cognitive, or motivational
processes, increasing behavioral competencies,
or altering the social conditions under which
people live & work.
Cont…..
• Self-efficacy beliefs provide the foundation for
human motivation, well-being and personal
accomplishment.
• People who regard themselves as highly
efficacious act, think & feel differently from those
who perceive themselves as inefficacious.
• Because individual’s operate collectively as well
as individually, self- efficacy is both a personal &
social construct.
Self-Efficacy
• Self-efficacy is the belief in one’s
effectiveness in performing specific tasks.
(Bandura, 1986)
Self – efficacy in DM type II
Self- monitoring of
Blood glucose,
Compliance with Rx
Follow Dietary restriction.
Control weight
Regular exercise.
Regular follow ups in cc.
Health outcome (improved health)
Develop habits of
positive thinking,
willingness to do
Actions and
self-reflection
Treatment
Nurse
Health Educator.
Persuader
Counselor
Family
HEALH CARE PROGRAMS
Nursing diagnosis
• Fear r/t diagnosis of chronic illness
• Knowledge deficit r/t control of disease/
prevention of complications.
• Risk of ineffective coping r/t chronic
disease
• Risk of noncompliance r/t the complexity
of the prescribed regime and follow up.
Nsg interventions
• Explain to the patient that the disease is controllable and
the symptoms can be reduced by improving behaviors
like:
-Control on weight through a weight reduction program
and exercise. Use of stairs instead of elevators, and a
regular program of walk, starting from small distance to
gradually increasing the distance.
-Reduction of calories in diet. Limit fat intake to about 25
percent of total calories. For example, if the food choices
add up to about 2,000 calories a day, should eat no
more than 56 grams of fat.
-Diet can be planed with the dietition. The patient can be
asked to check food labels for fat content too.
Cont…..
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Avoid taking saturated fats coming from
animals meats & dairy products like milk,
cheese and ice cream; and in some kinds of
cooking oils.
Reduce serving sizes of foods (such as meat,
desserts, and foods high in fat). Increase the
amount of fruits and vegetables in the diet.
Controlling carbohydrates in diet, such as:
pasta, bread, rice, potatoes
Cont….
• The patient is allowed to choose activities
he/she enjoys. Some ways to work extra activity
into daily routine:
• Take the stairs rather than an elevator or
escalator.
• Park at the far end of the plot and walk.
• Get off the bus a few steps early and walk the
rest of the way.
• Walk or ride bicycle instead of drive whenever
he/she can.
Cont….
• Compliance with Rx. The medicine must
be taken as prescribed by the physician, at
the right time in the right dose.
• Regular follow ups in cc, once in three
months, with raflo checks and lipid profile
and review of risk of appearance of 3
cardinal pathies.
Acknowledgements
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Miss Salma Jaffer
Ms Saleema Moiz
Ms Zubaida ( Diabetic cc nurse)
All Collegues
References
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Anne.J., ‘Diabetes Causes and Prevention,
retrieved from http://www.a1articles.com on
9/12/2007
Author: Bandura.A. (1986), ‘Social foundation of
thought and action’: a social cognitive
theory, England cliffs NJ, Prentice Hall
‘Diabetic diet information, what should you
eat’,retr. From http://www.a1articles.com on
7/12/2007
Pajares F., ‘Overview of Social Cognitive Theory And of
Self-Efficacy’, retrieved from www.healthology.com
on 7/12/2007
Porth, C. M. (2004). Pathophysiology: Concepts of altered
health states (7th ed.). New York: Lippincott.