Adult Health Nursing

1. Unit IX- ADVANCE NURSING
MANAGEMENT OF ENDOCRINE DISEASES
Diabetes Mellitus
BY
SEHRISH NAZ
RN, Post RN, MSN
Lecturer, Institute of Nursing Sciences, Khyber
Medical University
Subject: Adult Health Nursing
2/8/2020 Post RN semester one 1

2. Objective
At the end of the unit, students will be able to:
 Utilize Functional health pattern to identify patients
problems related to endocrine disorders including: Diabetes
Mellitus
 Integrate pathophysiology and pharmacology concepts of
Diabetes Mellitus
 Apply nursing process with support on Evidence-Based
Nursing (EBN) to provide to the clients with Diabetes
Mellitus
 Discuss the holistic approach for nursing management of
the patient with Diabetes Mellitus
 Develop a teaching plan for a client experiencing disorders
of the Diabetes Mellitus
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Objective

3. Endocrine system
• The endocrine system is a chemical messenger system
comprising feedback loops of hormones released by
internal glands of an organism directly into the circulatory
system, regulating distant target organs.
• In humans, the major endocrine glands are the thyroid
gland and the adrenal glands.
• In vertebrates, the hypothalamus is the neural control
center for all endocrine systems. The study of the
endocrine system and its disorders is known
as endocrinology. Endocrinology is a branch of internal
medicine.

5. Anatomy of the pancreas
• The pancreas is an elongated, tapered organ located
across the back of the belly, behind the stomach.
• The right side of the organ—called the head—is the
widest part of the organ and lies in the curve of the
duodenum, the first division of the small intestine.
• The tapered left side extends slightly upward—called
the body of the pancreas—and ends near the spleen—
called the tail.

6. Types of pancreatic glands
• The pancreas is made up of 2 types of glands:
Exocrine
• The exocrine gland secretes digestive enzymes.
These enzymes are secreted into a network of
ducts that join the main pancreatic duct. This runs
the length of the pancreas.
Endocrine
• The endocrine gland, which consists of the islets
of Langerhans, secretes hormones into the
bloodstream.

8. Functions of the pancreas
The pancreas has digestive and hormonal functions:
• The enzymes secreted by the exocrine gland in the pancreas help
break down carbohydrates, fats, proteins, and acids in the
duodenum.
• These enzymes travel down the pancreatic duct into the bile duct
in an inactive form. When they enter the duodenum, they are
activated.
• The exocrine tissue also secretes a bicarbonate to neutralize
stomach acid in the duodenum. This is the first section of the
small intestine.
• The main hormones secreted by the endocrine gland in the
pancreas are insulin and glucagon, which regulate the level of
glucose in the blood, and somatostatin, which prevents the release
of insulin and glucagon.

9. Case Study
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Demographic Data
Name : XYZ Gender: Male
Weight: 72 Kg DOA:12-10-2017
Age :52 Years DOD:16-10-2017

10. Chief complaint:
 Excessive thirst
 Frequency of urination
 Excessive hunger
 GBW (generalize body weakness)
 Retinopathy
Past Medical : Known DM type 2 & HTN
Surgical History: Not significant.
Social History: Poor
Family History: HTN (Mother)
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Cont..
Parameters
Pulse rate 88
Respiratory rate 24
B.P 180/100

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Parameters Reported value Normal value
Blood Sugar 240mg/dl 60-180 mg/dl
Fasting blood sugar 180mg/dl 70-100mg/dl
Glycohemoglobin ( HBa1C) 10.7% 4.27-6.5
CBC -WBC 10.5 4.00-11.0 x 10 9/L
HBG 13 g/dl 11.5-17.5 g/dl
Blood urea 28 mg/dl 18-45 mg/dl
Uric acid 1.2 mg/dl 0.64-1.2 mg/dl
Complete biological & pathological details

12. Diabetes mellitus
Diabetes mellitus is a disorder in which blood
sugar (glucose) levels are abnormally high
because the body does not produce enough
insulin to meet its needs. Urination and thirst
are increased, and people may lose weight
even if they are not trying to.

13. Hormone effect on blood glucose
Hormone Action Result on Blood
Glucose
Insulin Helps glucose enter into cell
Stimulate glycogenesis
Lower
Glucagon Stimulate glycogenolysis Raises
Epinephrine Stimulate glycogenolysis Raises
Growth
hormone
Stimulate catabolism of fat Raises
Glucorticoids Fat and muscle cells resistant Raises
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14. • Insulin is secreted by beta cells in the pancreas and it is an
anabolic hormone.
• When we consume food, insulin moves glucose from blood to
muscle, liver, and fat cells as insulin level increases.
• The functions of insulin include the transport and metabolism
of glucose for energy, serves as the signal of the liver to stop
releasing glucose, enhancement of the storage of dietary fat in
adipose tissue, and acceleration of the transport of amino acid into
cells.
• Insulin and glucagon maintain a constant level of glucose in the
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Functions of Insulin

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17. In people without diabetes,
glucose stays in a healthy range because
Insulin is
released at the
right times
and in the
right amounts.
Insulin helps
glucose enter
cells
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Normal Blood Glucose Control

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19. Type 1 diabetes
 Insulin dependent diabetes mellitus (IDDM), or juvenile-
onset diabetes mellitus
Type2 diabetes
 Non-insulin dependent diabetes mellitus (NIDDM), or adult-
onset diabetes mellitus (AODM).
Gestational diabetes
 Significant hormonal changes.
Secondary
 Chronic pancreatitis ( toxins like excessive alcohol)
 Other hormonal disturbances
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Classification of Diabetes

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22. Peripheral insulin resistance
Impaired regulation of hepatic glucose production
declining β-cell function
Eventually leading to β -cell failure
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Pathophysiology of Type 2 Diabetes
(NIDDM)

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Clinical Manifestation

25. Diagnostic criteria of diabetes mellitus (WHO)
• Symptoms (polyuria, polydipsia, weight loss, DKA)
• + Random blood glucose level ≥ 11.1 mmol/l (≥ 200 mg/dl)
or
• Fasting blood glucose level ≥ 7.0 mmol/l (≥ 126 mg/dl), (no
caloric intake 8 h)
or
• 120 min blood glucose in OGTT ≥ 11.1 mmol/l (≥ 200
mg/dl)
or
• HbA1c ≥ 6.5 %
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Diagnostic Criteria

26. • Serum glucose : Increased 200–1000 mg/dL .
• Fasting glucose: greater than or equal to 120mg/dl .
• Fatty acids: Lipids, triglycerides, and cholesterol level
elevated.
• Serum osmolality: Elevated( normal range 275-295 mOsm/L).
• Glycosylated hemoglobin (HbA1C): A result greater than 8%
represents an average blood glucose of 200 mg/dL and signals
a need for changes in treatment.
• Serum insulin: May be decreased/absent (type 1) or normal to
high (type 2).
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Assessment and Diagnostic Findings

27. • Electrolytes
• Arterial blood gases (ABGs): Usually reflects low pH and
decreased HCO3 (metabolic acidosis) with compensatory
respiratory alkalosis.
• Thyroid function tests: Increased thyroid activity can increase
blood glucose and insulin needs.
• Urine: Positive for glucose and ketones.
• Cultures and sensitivities: Possible UTI, respiratory or wound
infections.
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Cont..

28. Management
Nutritional
therapy
Exercise
Monitoring
Pharmacologic
therapy
Education
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29. Nutrition therapy (NT)
NT is an evidence-based application of the nutrition
care process for the treatment of a disease or
condition through the modification of nutrient or
whole-food intake provided by a registered
dietitian/nutritionist.
Effective nutrition therapy strategies for people with
type 2 diabetes should emphasize reduced energy
intake along with simplified meal plans such as
healthful food choices or education on portion
control.
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30. cont.
To achieve modest weight loss, intensive lifestyle
interventions (physical activity, counseling about
nutrition, and behavior change) with ongoing support
are recommended.
After diabetes medication is started, nutrition therapy
continues to be a key part of type 2 diabetes self-
management.
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31. Patient Education
 Patients should be educated to practice self-care. This
allows the patient to assume responsibility and control of
his / her own diabetes management. Self-care should
include:
Blood glucose monitoring.
Body weight monitoring.
Foot-care.
Personal hygiene.
Healthy lifestyle/diet or physical activity.
Identify targets for control.
Stopping smoking.
Guidence about Hyperglycemia & Hypoglycemia.
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32. Class Mechanism of action Indication(s)
Sulfonylureas and
repaglinide
Increase insulin secretion Insulinopenia
Biguanides
(Metformin)
Inhibit hepatic glucose
production
Increase the sensitivity of
peripheral tissues to insulin
Obesity+ insulin
resistance
Thiazolidenediones
Decrease peripheral insulin
resistance
Reduce fatty acids
Insulin resistance
α-glucosidase
inhibitors
Slow absorption of
carbohydrates
Postprandial
hyperglycemia
Pharmacotherapy
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33. 1- Acute complications
 Hypoglycemia
 Diabetes Ketoacidosis (DKA)
2- Chronic complications:
 Diabetic retinopathy
 Diabetic nephropathy
 Diabetic neuropathy
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Complications of Diabetes Mellitus

34. Approaches to prevention of diabetic complications include the
following:
 HbA1c every 3-6 months
 Yearly dilated eye examinations
 Foot examinations at each visit
 Blood pressure greater than 130/80 mm Hg.
 Get help to quit smoking
 Be active
 Make healthy food choices
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Preventive Measures

35.  Ineffective health maintains related to demonstration
of uncontrolled diabetes and reporting lack of
education about diabetes as evidence by high blood
sugar and knowledge deficient about controlled
diabetes.
 Fluid Volume Deficit related to osmotic diuresis as
evidence by increase thirst and dry mouth.
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Nursing Diagnosis for Diabetes
Mellitus

36. Nursing Interventions
• -The nurse will educate the patient on how to take his
blood sugar and interpret the results.
• The nurse will educate the patient on how to take the
medication.
• The nurse will educate the patient on how often and
when he needs to check his blood sugar.
• The nurse will consult with the dietitian to educate
the patient on diet regime for diabetics.
• The nurse will encourage the patient to develop a
daily menu that meets his diabetic needs.
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37. Nursing Intervention
 Monitor input and output to provide estimates of the
need for fluid replacement, renal function, and
effectiveness of the therapy given.
 Monitor vital signs.
 Assess skin turgor, and mucous membranes.
 Measure weight every day to provide the best
 Provide fluid therapy as indicated.
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38. The responsibility of the healthcare team members does not end
when the patient is discharged. The following are guidelines
that should be discussed before the patient is discharged from
the hospital.
• Patient empowerment is the focus of diabetes education.
• Patient education should address behavior change, self-
efficacy, and health beliefs.
• Simplify the treatment regimen if it is difficult for the patient
to follow and Adjust according to meet patient requests.
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Discharge and Home Care Guidelines

39. • Encourage the patient to pursue life goals and
interests, and discourage an undue focus on diabetes.
• Educate client on wound care, Medication, and
glucose monitoring.
• Instruct client to comply with the appointment with
the healthcare provider at least twice a year for
ongoing evaluation and routine nutrition updates.
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Cont..

40.  Insulin Pumps.
 Implantable and inhalant
insulin delivery.
 Transplantation of pancreatic
cells.
 Vaccine under research:
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New trends

41. • Brunner, L. and Suddarath, D. (2010). Text Book of Medical Surgical
Nursing. 12th Edition. J.B By Suzanne C. Smeltzer.
• Baynes HW (2015) Classification, Pathophysiology, Diagnosis and
Management of Diabetes Mellitus. J Diabetes Metab
6:541.doi:10.4172/2155-6156.1000541.
• Ionescu-Tirgoviste, Constantin; Gagniuc, Paul A.; Gubceac, Elvira;
Mardare, Liliana; Popescu, Irinel; Dima, Simona; Militaru, Manuella
(2015-09-29). "A 3D map of the islet routes throughout the healthy human
pancreae“, Scientific Reports. 5: 14634. PMC 4586491 . PMID 26417671
doi:10.1038/srep14634.
• Malaisse W. 1996 Metabolic signaling of insulin secretion. Diabetes Rev . 4
:145 –159 .
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References

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