A. MacLeod, 2002
Control of Blood Glucose – Diabetes
Mellitus
Ann MacLeod, RN, BScN, MPH
1
Objectives


Understand pathophysiology of diabetes
Describe the following relating to diabetes
• Assessment
• Nursing diagnoses
• Management
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Diabetes Mellitus
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Definition: a metabolic disorder
characterized by glucose intolerance
an imbalance between insulin supply and
demand
not enough insulin, or insulin isn’t effective
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Pathophysiology
 BS
  urine glucose
 H20 loss due to
hyperosmolarity
 Usable fat combustion
glucose
 brain starvation
tissue food for bacteria
glucose
serum atherosclerosis
cholesterol
?
small vessel disease
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 glycosuria
 polyuria
 ketoacidosis resp
metab. Acidosis
 coma
infections
 miocardial infarcts
gangrene
kidney damage,
retinopathy, neuropathy
4
Types of Diabetes

Type 1: IDDM: insulin dependent

Type 2: NIDDM: not insulin dependent
Associated with other conditions:
Gestational

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Type 1 diabetes - IDDM

Diseased pancreatic beta cells not producing insulin
 Genetic? Environmental? Autoimmune?
 Recall insulin
• Inhibits glycogenolysis (breakdown of stored glucose in the
liver)
• Inhibits gluconeogenesis (making new glucose from
nutrients)
• Inhibits fatty acid breakdown into glucose(ketones & acid
& glucose products)
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Type II diabetes - NIDDM


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Cells receptors not sensitive or resistant to
insulin  insulin unable to glucose
transport into cell
Insulin still being produced
Risk factors obesity & sedentary
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Gestational diabetes
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Hyperglycemia due to excretion of
hormones during pregnancy
Usually return to normal after delivery
At risk for Type II
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Risk Factors for Diabetes
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Heredity: Does someone in the family have the disease?
Black, Aboriginal
Obesity
Age > 45
Stress
hypertension
HDL < 35 mg/dl
gestational diabetes or large babies
Sex: 3x more women
viral infections of pancreas
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Diagnostic tests
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Random Blood Sugar > 11mmol/l
Fasting Blood Sugar (FBS) > 7
2 hr. pc. Blood sugar
Glucose tolerance test
Urine testing for sugar and acetone (diabetic
protocol)
HgbA 1c
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Further Assessment

Polydypsia

Glucosuria

polyuria

weakness, fatigue

polyphagia
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Nursing Diagnoses
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Risk for fluid volume deficit r/t polyuria
Altered nutrition r/t imbalance of insulin, food and
physical activity
Knowledge deficit r/t self-care
Potential self-care deficit r/t blindness neuropathy
Anxiety
Altered coping
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Collaborative Management

Diet: based on body 
wt. And activity: 5060% CHO, 12-20%

protein, 20-30% fat
BMI <30
 typically 3 meals /day

with an eve. snack
Monitoring of blood
glucose, glucometers
oral hypoglycemic
agents: stimulate beta
cells to produce insulin
injectable insulin
 excercise
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Nursing Interventions

Close monitoring for hypoglycemia
especially when blood glucose levels are
low ie. Fasting for tests, surgery, meal
skipping, nausea, vomiting, other short
lived illnesses
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Insulin

Hormone secreted by the pancreas when blood
glucose rises.
 Needed to transport glucose from the blood into
the cells of fat and muscle
 most common source is beef/pork
 now largely biosynthetic sources ( anything
ending with “lin” made with recombinant DNA in
a lab
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Insulins
Humulin R
Clear
Can be IV
5-20 u ac
NPH, Humulin N Cloudy
Novolin N Lente
Given qd,bid
Humulin L
Novolin L
Onset .5h
Peak 2-3h
Duration 5-7
Onset 1- 1.5
Peak 8-12
Duration 1824
Humulin U,
Ultralente
Cloudy,
Onset 4-8
Duration 36+
hypoglyc.
Peak 10-30 h
during sleep
NPH/Regular
Cloudy
Varies with Varies with
70/30 or 50/50
dose
dose
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Most common
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Oral Hypoglycemics

Sulphonylureas eg. glyburide
• stimulate b cells to secrete insulin
• do not use with renal impairment, no etoh
 Alpha-Glucosidase inhibitors
• inhibit absorption of Sugars (blocks amylase
etc.
 Biguanide eg. Metaformin
•  liver gluconeogenesis
• intestinal absorption of glucose
• geriatric risk for DKA, monitor renal function
or liver disease A. MacLeod, 2002
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Insulin

Various insulin delivery systems are being
manufactured, including insulin pens, sq
ports, sq infusions, IV infusions
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Complications of Diabetes
Diabetic Ketoacidosis:

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a life-threatening syndrome
onset: hours>>days
severe hyperglycemia and acidosis resulting
from insulin deficiency or absence
associated with failure to take insulin, new
Dx., infection
Hyperglycemia acts like an osmotic diuretic
and causes severe fld. And electrolyte loss
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( K+)
Assessment Diabetic
Ketoacidosis

Are a result of
hyperglycemia and
fluid and electrolyte
losses
 alt. LOC
 kaussmaul resp.
 tachycardia

Dry flushed skin, poor
turgor, dry mucous
membranes
 polyuria, polydypsia
 acetone breath
 weakness
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Assessment DKA cont’d
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Blood work: blood glucose can go as high
as 25-80 mm/L
electrolyte imbalances
severe dehydration
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Collaborative Management

Fluid replacement
 rapid acting insulin
 restore electrolyte
levels

Treatment of
underlying cause
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Nursing Process

Fluid volume deficit

Altered peripheral
tissue perfusion

Risk for Injury

knowledge deficit
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Hypoglycemia
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A lowering of blood glucose caused by
excessive insulin or hypoglycemic agent
may also be caused by: skipping meals,
++exercise, vomiting
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Hypoglycemia


Sudden onset:
typical scenario: hypoglycemia occurs
during the time of peak action of insulin or
hypoglycemic agent. Especially at night
when ct. is asleep, or hasn’t eaten a bed
time snack
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Assessment
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For some cts. You will see symptoms when
blood glucose drops below 5
pale, cold, clammy, perspiration
weak, hunger, tachycardia,headache, double
vision
confusion, slurred speech, coma
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Management
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Admin. Of rapid acting sugar (fruit juice,
cola, hard candy, then follow it with a
complex CHO and protein)
50% dextrose IV works in less than 10 min
(25-50 mls)
glucagon
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Nursing Process

Alt. Protection r/t risk
of seizure and brain
damage

knowledge deficit r/t
disease process

Knowledge deficit r/t
diagnostic testing,
indicators of
hypoglycemia,
theraputic regime
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Hyperosmolar Hyperglycemic,
Non ketotic syndrome
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Life threatening lack of insulin causing
severe hyperglycemia
usually elderly cts. With inadequate Tx. Or
undiagnosed DM.
Often have pre-existing cardiac or
pulmonary problems
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Assessment
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Same as DKA as well as seizures
resp. shallow with apneic episodes
polyuria, polydypsia, fatigue, weakness
hypotension, increased HR. T.
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Risk Factors
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Undiagnosed DM
gram negative infection
over 50 yrs. In age
cardiac or lung problems
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Chronic Complications of
Diabetes Mellitus

Risk factors: ageing, dietary habits, lack of
control of blood sugars, duration of illness,
lack of exercise, complicating pre-existing
medical conditions, SMOKING
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Complications of Diabetes
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Three main types:
1) macrovascular
2) microvascular
3) neuropathy
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Macrovascular
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Related to degenerative changes in the large
blood vessels
MI: r/t coronary artery disease
CVA: r.t cerebral artery disease
PVD: r/t peripheral vasc. Disease
infection d/t vasc. insufficiency
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Microvascular
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
Nephropathy: damage to capillaries that
supply the glomeruli: early sign is
proteinuria, may progress to end stage renal
disease
Retinopathy: damage to capillaries of
retina>scar tissue>blindness
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Neuropathy
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Most common chronic complication of
diabetes
when circulation to axons and dendrites is
impeded, transmission of impulses slows
Ax. Parestesia: prickling, tingling,may also
be autonomic
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Ongoing Assessment
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Activity
diet
medication
glucose monitoring
eyes ( retinopathy)
skin and mucous membranes
Cardio vascular system BP, tissue perfusion
Genitourinary system - infections, difficulty
voiding,
Neuropathies
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Client Teaching with regards to
diabetes

Importance of balance
between insulin, diet,
exercise
 more frequent checks
of BS during episodes
of brief illness, injury
or stress

Never alter insulin
dosage unless advised
by a MD.
 Insulin use:how to
give self a SQ
injection (begin with
simple and work to
complex
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Client Teaching

Dietary modifications

exercise

hygiene and safety
measures
 foot care

Coping skills, with
careful consideration
of growth and
development
 techniques for
monitoring blood
glucose levels
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