DIABETES MELLITUS
Rachel S. Natividad RN, MSN, NP
Review A&P
Role of Insulin

Insulin:
– Counters metabolic
activity that would
increase blood
glucose levels
– Enhances transport
of glucose into body
cells
– Lowers blood glucose
levels
Physiology Cont: Insulin


Basal (continuous)
Prandial (Bolus)
*Blood glucose increases within
10 minutes of the beginning
of a meal*
Diabetes Mellitus
A
disorder of carbohydrate, protein,
and fat metabolism resulting from an
imbalance between insulin
availability and insulin need. (Porth,
2002)
 End
Result : HYPERGLYCEMIA
Physiology Cont.:Glucose Control
Patho: DM Type 1
Patho Cont.: DM Type 2
Normal Physiology
Pathophysiology-Cont.:DM Type 2
DM 1&2: The big difference…
DM TYPE 1
No endogenous insulin
DM TYPE 2
Some endogenous
insulin
Tx requires insulin injections
Tx diet and exercise 1st,
then pills and /or insulin
Usually < age 30 yrs.
Usually over 30 yrs. (peaks
at 50)
Ketosis prone (DKA)
Former names: IDDM
(Juvenile)
Diabetes Type I
Thin to normal body
weight
Acute metabolic complications
(DKA)
no ketosis
NIDDM (maturity/adultonset)
Diabetes Type II
Usually Overweight
Chronic vascular complications
Case Study
Diabetes: Clinical Manifestations
THE 3
POLYs
POLYDYPSIA
POLYURIA
14
POLYPHAGIA
Diabetes Clinical Manifestations
Cont: Signs and Symptoms
Early signs
 3 Polys
 Weight loss
 Fatigue/Always tired
 Visual Blurring
Late signs
 Any of the 3 Polys
 Infections
 Numbness/ tingling of
feet or leg pain
 Slow healing wounds
 Chronic Complications
Diabetes: Dx Tests

Fasting Blood Glucose
(FBG): <100 mg/dL
– Iggy: 70-110 mg/dL
*Random/Casual Blood
Glucose*:<200 mg/dL


Oral Glucose Tolerance Test
(OGTT): < 140 mg/dL
Glycosylated Hemoglobin
(HgbA1C): 4-6%
Check MD orders or agency
protocol for frequency of
BS Monitoring
In General:
AC&HS if pt able to eat;
Q4-6 hours if NPO or tube
feedings
Diabetes: Diagnostic Tests Cont.
 Glycosylated
hemoglobin test –
Hemoglobin A1C (HbA1c)
– measures the amount of glycosylated
hemoglobin (hemoglobin that is
chemically linked to glucose) in blood.
– Normal -4-6%
– Target range DM patient <7%
HbA1C Control
NormalCriteria for the Diagnosis of Diabetes Mellitus
– FPG <110 mg per dL
– 2hr OGTT <140 mg per dL
Diabetes- positive findings from any two of the following tests on
different days:
– Symptoms of diabetes mellitus* plus casual (random)
plasma glucose concentration >=200 mg / dL
or
– FPG >=126 mg per dL
or
– 2hr OGTT >=200 mg per dL after a 75-g glucose load
Diagnostic Tests – Cont.
Is it Diabetes Yet?
>126
>200
>6
100-125
140-200
Impaired Fasting Glucose
Impaired Glucose Tolerance
<100
<140
<6
Acute Complications
Diabetic
Ketoacidosis (DKA)
 BS > 300 mg/dL
 Classic symptoms
 Ketosis

HyperglycemicHyperosmolar
Nonketotic Syndrome
(HHNS)
 BS > 800 mg/dL
 Similar symptoms
 No Ketosis

Check urine for
ketones
(ADA)
Chronic Complications of DM
Effects on Blood Vessels
Blood Vessel
Lumen
Chronic Complications - Macrovascular
 Cardiovascular
– heart disease
 Cerebrovascular
– Stroke
DM pts have heart disease
and stroke risks 2 to 4 X
higher than non-DM pts
 Peripheral
disease
vascular
Chronic ComplicationsMicrovascular :
 Diabetic
Retinopathy
The leading cause
of new cases of
blindness in adults
ages 20 - 74
Chronic ComplicationsMicrovascular
Nephropathy
The leading cause of
end-stage renal
disease (ESRD),
occurs in about 20 40% of patients
with diabetes
Chronic Complications-Microvascular
Diabetic Neuropathy -
the poor blood supply
will cause the nervous system to malfunction
Chronic ComplicationsMicrovascular
Amputation of Toes
Chronic ComplicationsMicrovascular

Sexual problems for men

Sexual problems for women
erectile dysfunction
retrograde ejaculation
decreased vaginal
lubrication
decreased sexual
response

Urologic problems for men
and women
urinary tract infections
neurogenic bladder
Chronic ComplicationsMicrovascular
 Gastroparesis
Nerve damage to the
digestive system most
commonly causes
constipation. Damage can
also cause the stomach to
empty too slowly
MANAGEMENT OF DM
 Regular
Blood Glucose Monitoring
Drug Therapy
32
Diet
Exercise
Management: Diet & Exercise
Diet : Diabetes Food Pyramid
Diet Cont: What to do???
Diet Cont.
Carb-Counting
Diet Cont: Glycemic Index
Diet Cont.:
Getting the balance right
Get your portions right!!
Management: Exercise

Helps regulate
blood glucose


Increases insulin
effectiveness and
sensitivity in the
body.
Must monitor
insulin and food
intake to match
exercise regimen.
Drug Therapy
Insulin
&
Oral Antidiabetic Agents
Drug Therapy: Insulin Types

Fast-acting insulin
– Rapid Acting Insulin Analogs
 Aspart,
Lispro, Glulisine
– Regular Human Insulin

Intermediate-acting insulin
– NPH Human Insulin
– Pre-Mixed Insulin
 Humulin

BOLUS
Used to lower
blood sugar
after eating a
meal
70/30, Humalog 75/25
Long-acting insulin
– Insulin Glargine, Insulin
Detemir
BASAL
Used to lower
blood sugar
throughout the
day and night
Drug Therapy Cont.: Insulin
Onset - how soon it starts to work in the blood
Peak - when the insulin has the greatest effect
on blood sugar levels
Duration – how long it keeps working
Drug Therapy Cont:
Goal of Insulin Therapy
Basal and Bolus Insulin Coverage
Drug Therapy Cont:
Sample Insulin Regimen
(NPH & Regular insulin)
Drug Therapy-Insulin Cont:
Rapid Acting “Logs”
Humalog (insulin lispro)
Novolog (insulin aspart)
Bolus insulin
 Onset 15 min; peaks
1-2 hrs; lasts 4-6
hours
 Ideal for meal
coverage

“Give the shot while
the plate is hot!”
Drug Therapy-Insulin Cont:
Short Acting: Regular Insulin
Regs
Bolus insulin
 Onset ½-1 hr;
peaks 2-4 hrs; lasts
6-8 hrs

Give 30 minutes to 1
hour before a meal
Drug Therapy-Insulin Cont:
Short Acting: Regular Insulin
♪ It’s time give you your regular insulin ♪
♪ It’s time to give it 30 minutes before your
plate is in ♪
♪ Come back to check you in 2 (hours) ♪
♪ Watch out for shakes and sweats too ♪
♪ If your lucky you’ll have no clue!!!! ♪
Drug Therapy-Insulin Cont:
Rapid Acting
(Humalog/Novolog)
Rapid onset
1-2 hour peak
Limited duration
VS.
Short Acting (Regular
Insulin)
Delayed onset
Peaks in 2-4 hr
Lasts 6-8 hours
Drug Therapy-Insulin Cont:
Intermediate acting: NPH Insulin





Basal insulin: covers blood
sugar between meals
Satisfies overnight insulin
requirement
Onset 1-2 hrs, peaks 6-10 hrs,
lasts 12+ hrs
Need snack if NPH given at 5
pm (only)
Ideal to be given at 9 pm (HS)
to address Dawn
Phenomenon
L
Drug Therapy-Insulin Cont:
ong-Acting: Peakless Insulins!!!
Lantus (insulin glargine)
Levimir (insulin detimir)
 Basal
Insulin
 Onset 1.5 hrs; no peak (max effect in 5
hrs); lasts 24 hours
 No risk for hypoglycemia
 Do not mix with other insulins – becomes
inactivated when mixed with other insulins
Lantus
Drug TherapyInsulin Cont:
Hypoglycemia

BS < 60-70 mg/dL

An acute
complication
of insulin administration

Tx: (15/15 or
20/20 Rule)
– Give 15/20 g simple
carb and recheck
BG in 15/20 minutes
Synthetic injectables
 Byetta:
Synthetic incretin mimetic
hormone
– Indicated for patients with type 2
diabetes who don’t use insulin
 Symlin:
Synthetic analogue of
human amylin
– Approved for use with insulin in adults
with type 1 and type 2 diabetes
Drug Therapy Cont:
Other Methods of Administration
For Uncontrolled DM 1 0r 2
Rapid-acting insulin
Continuous IV insulin infusion




Used to maintain glycemic control
in hospitalized patients with high
blood glucose levels; in DKA and
HHNS
Regular insulin may be used IV
May also be given preoperatively
or postoperatively
More frequent BS monitoring ( q12 hours per agency protocol)
Drug Therapy Cont:
Oral Antidiabetic agents
(see handout)
New Oral Med
 Januvia
(Sitagliptin)
– An oral drug that reduces blood sugar
levels in patients with type 2 diabetes.
– Sitagliptin is the first approved
member of a class of drugs that inhibit
the enzyme, dipeptidyl peptidase-4
(DPP-4).
Oral Agents: How do they work?
Acute Complication
of Insulin and (some) Oral Meds
Hypoglycemia
Hyperglycemia
Critical Thinking Exercises
Course Packet
pp. 81-84
Diabetic Teaching
Needs
Disease process
S/S of hyperglycemia and hypoglycemia
Blood sugar monitoring
Diet
Exercise
Drug therapy
Sick Day Rules
Complications (acute and chronic)
Prevention: Foot care, eye exam etc.
DIABETES can be controlled!!!