Assessment and Management of Patients with Diabetes Mellitus, DM TYPE 1 AND 2

1. A thorough discussion
about the Assessment and Management of Patients with
Diabetes Mellitus
Prepared by: Dave Jay S. Manriquez RN.
Diabetes Mellitus
A heterogeneous group of disorders characterized by an elevation in the level of glucose
in the blood.
In Diabetes there may be a decrease in the body’s ability to respond to insulin and/or a
decrease or absence of insulin produced by the pancreas.
Diabetes Mellitus
The resulting hyperglycemia may lead to acute metabolic complications such as diabetic
ketoacidosis and hyperosmolar nonketotic syndrome.
Long term hyperglycemia may contribute to chronic microvascular complications,
neuropathic complications, and macrovascular diseases.
How will you know if you are a diabetic?
If you urinate frequently, experience excessive thirst and unexplained weight loss.
If your casual blood sugar (plasma glucose) level is higher than 200mg/dl.
If you have fasting plasma glucose level of not more than 126mg/dl.
Who are at risk of diabetes?
children of diabetics
obese people
people with hypertension
people with high cholesterol levels

2. people with sedentary lifestyles
Types of Diabetes
Type 1 : Insulin-dependent diabetes mellitus
Type 2 : Non-insulin-dependent diabetes mellitus
Diabetes mellitus associated with other conditions or syndromes
Gestational diabetes mellitus
Types of Diabetes
Type 1: About 5% to 10% of people with Diabetes. A form of diabetes wherein there is
inadequate amounts of insulin are produced by the pancreas, resulting in the need for
insulin injections to control the blood glucose. It is also characterized by sudden onset
usually before the age of 30 years.
Type 2: About 90% to 95% of people with Diabetes. Cause by a decrease in the
sensitivity of the cells to insulin and the decrease in the amount of insulin produced. It
can be treated with diet, oral hypoglycemic agents and insulin injections. It occurs most
frequently in people who are over 30 years of age and obese.
Learn More about Diabetes Mellitus with this Song Rap….
Epidemiology
Diabetes is the third leading cause of death by disease, mostly because of the high rate of
coronary artery disease among people with diabetes.
Diabetes is the leading cause of new blindness (among 25 to 74 years old) and
nontraumatic amputations in the United States.
25% of patients on dialysis have diabetes.
Hispanic, black, and some Native American populations have a higher rate of diabetes
than the white populations.
Epidemiology
Diabetes in 2007
23.6 million — Number of Americans who had diabetes

3. 12.2 million — Number of Americans 60 and older with diabetes
5.7 million — Number of undiagnosed cases of diabetes
1.6 million — Number of new cases of diabetes in adults
186,300 — Number of people younger than 20 with diabetes
$174 billion — Economic cost of diabetes
Source: American Diabetes Association
Epidemiology
There are 2.8 million Filipinos who were diagnosed with diabetes.
From 1993 to 1997, 2.1 percent of the deaths recorded are due to diabetes and annually
the cases of diabetes continue to increase by 2.5 percent.
What is an Insulin?
Secreted by the beta cells, which are one of four types of cells in the islets of langerhans
in the pancreas. It is considered to be an anabolic, or storage, hormone. When a meal is
eaten, insulin secretion increases and moves glucose from the circulation into muscle,
liver, and fat cells.
During “fasting periods” (between meals and overnight) there is a lower production of
insulin accompanied by an increased release of another pancreatic hormone the glucagon.
The net effect of the balance between insulin and glucagon levels is to maintain a
constant level of glucose in the blood through release of glucose from the liver.
The Pancreas….
Learn more about pancreas with this video presentation….
Insulin Functions….
Stimulates storage of glucose in the liver and muscle (in the form of glycogen).
Enhances storage of dietary fat in adipose tissue.
Accelerates transport of amino acids (derived from dietary protein) into the cells.
Insulin also inhibits the breakdown of stored glucose, protein, and fat.
Learn More About Insulin with this video presentation….
Classification of Diabetes Mellitus and Related Glucose Intolerance

4. Classification of Diabetes Mellitus and Related Glucose Intolerance
Classification of Diabetes Mellitus and Related Glucose Intolerance
Etiology of Type 1 Diabetes
Combination of Genetic, Immunologic, and possibly Environmental factors contribute to
beta cells destruction.
Genetic – People do not inherit type 1 DM itself; rather, they inherit a genetic
predisposition, or tendency, toward developing type 1 DM. This genetic tendency has
been found in people with certain HLA (human leukocyte antigen) types. 95% of patients
with type 1 diabetes exhibit specific HLA types (DR3 or DR4). The risk of developing
type 1 DM is increased 3-5 times in people who have one of these two HLA types.
Etiology of Type 1 Diabetes
Immunologic – Abnormal response in which antibodies are directed against normal
tissues as if they are foreign. Auto antibodies against islet cells and against endogenous
(internal) insulin have been detected in people at the time of diagnosis.
Environmental – Certain viruses or toxins may precipitate the autoimmune process that
leads to beta cell destruction.
Learn more about Diabetes Mellitus Type 1 with this video presentation….
Etiology of Type 2 Diabetes
The exact mechanisms that lead to insulin resistance and impaired insulin secretion in
type 2 are still unknown at this time. But they say Genetic factor play an important role in
developing insulin resistance.
There are certain risk factors:
Age (insulin resistance tends to occur with age over 65)
Obesity
Family history
Ethnic group (Hispanic and American Indians)
Learn more about Diabetes Mellitus Type 2 with this video presentations….
World Health Organization Diagnostic Criteria for Diabetes Mellitus in
Adults

5. On at least two occasions:
Random plasma glucose > 200mg/dl
Fasting plasma glucose > 140mg/dl
2-hour sample during 75g OGTT (Oral Glucose Tolerance Test) > 200mg/dl
OGTT – The patient ingest high CHO (150-300g) meals for 3 days preceding the test.
After an overnight fast, a blood sample is drawn. Then a 75g CHO load, usually in the
form of carbonated sugar beverage (Glucola), is given to patient. The patient is instructed
to sit quietly, avoid exercise, smoking, coffee, and any other oral intake except water.
WHO recommends that after 2 hours a blood sample is drawn after glucose ingestion.
Learn more about Blood Glucose Monitoring with this video presentation….
Complications of Diabetes
Acute Complications: result from an imbalance in the treatment regimen.
Hypoglycemia (low blood sugar), which is also called insulin reaction or insulin shock.
Hyperglycemia (high blood sugar), which, if uncontrolled, may lead to diabetic
ketoacidosis (DKA) in type 1 diabetes or hyperosmolar nonketotic syndrome (HNKS) in
type 2 diabetes.
Complications of Diabetes
Chronic Complications of type 1 and type 2 diabetes generally occur 10 to 15 years after
the onset of diabetes.
Macrovascular (large vessel) disease – affecting coronary peripheral vascular, and
cerebrovascular circulations.
Microvascular (small vessel) disease – affecting the eyes (retinopathy) and kidneys
(nephropathy).
Neuropathic diseases – affecting sensorimotor and autonomic nerves and contributing to
such problems aqs impotence and foot ulcers.
Learn more about Chronic Complications of Diabetes with this video presentation….
Misconceptions Related to Diabetes and Its Treatment
Misconceptions Related to Diabetes and Its Treatment
Misconceptions Related to Diabetes and Its Treatment

6. Misconceptions Related to Diabetes and Its Treatment
Misconceptions Related to Diabetes and Its Treatment
Morning Hyperglycemia
Insulin Waning – Progressive rise in blood glucose from bedtime to morning. TT:
Increase evening dose of intermediate or long acting insulin.
Dawn Phenomenon – Relatively normal blood glucose until about 3am when the level
begins to rise. TT: Change time of injection of evening intermediate acting insulin from
dinner time to bedtime.
Somogyi Effect – Normal or elevated glucose at bedtime, a decrease at 2-3am to
hypoglycemic levels, and a subsequent increase caused by the production of counter
regulatory hormones. TT: Decrease dose of evening intermediate acting insulin or
increase evening snack.
Foot and Leg Problems in Diabetes
55% to 75% of lower extremity amputations are performed on people with Diabetes. 50%
of these amputations are preventable, provided patients are taught preventive foot care
measures and practice preventive foot care on a daily basis.
Three diabetic complications contribute to the increased risk of foot infections. They are:
A. Neuropathy – Sensory neuropathy leads to loss of pain and pressure sensation, and
autonomic neuropathy leads to increased dryness and fissuring of the skin (secondary to
decreased sweating).
Foot and Leg Problems in Diabetes
B. Peripheral vascular disease – Poor circulation of the lower extremities contributes to
poor wound healing and the development of gangrene.
C. Immunocompromise – Hyperglycemia impairs the ability of specialized leukocytes to
destroy bacteria. Thus, in poorly controlled diabetes there is a lowered resistance to
certain infections.
Diabetic foot ulcer begins with a soft tissue injury of the foot, the injury or fissure may go
unnoticed until a serious infection has developed. Drainage, swelling, redness (from
cellulitis) of the leg, or gangrene may be the first sign of foot problems that the patient
notices

7. Foot and Leg Problems in Diabetes
Treatment of foot ulcers involves bed rest, antibiotics, and debridement.
In peripheral vascular diseases, foot ulcers may not heal because of the decreased ability
of oxygen, nutrients, and antibotics to reach the injured tissue. Amputation may be
necessary to prevent further spread of infection.
Foot Assessment and Foot Care instruction are most important in dealing with patient
who are high risk of developing foot ulcers.
Duration of diabetes over 10 years
Age over 40 years
History of smoking
Decreased peripheral pulses
Decreased sensation
Anatomic deformities or pressure areas (such as calluses)
History of previous foot ulcers or amputation
Foot Care….
Preventive foot care includes properly bathing, drying, and lubricating feet (care must be
taken not to allow moisture to accumulate from water or lotion between the toes.)
Feet must be inspected on a daily basis for any redness, blisters, fissures, calluses or
ulcerations.
The interior surface of the shoes should be inspected for any rough spots or foreign
objects.
Feet should be examined on a regular basis by a podiatrist, physician, or nurse.
Foot Care….
Patients with thick toenails should see the podiatrist routinely for shaving of calluses and
trimming of nails.
Patients should be taught to wear well-fitting, closed toe shoes.
High risk behaviors should be avoided, such as walking barefoot, using heating pads on
the feet, wearing open toed shoes, and shaving calluses.
Toenails should be trimmed straight across without rounding the corners.
Types (Levels) of Amputations

8. Amputations can be divided into two types: minor and major.
Minor or limited amputations are amputations where only a toe or part of the foot is
removed.
A ray amputation is a particular form of minor amputation where a toe and part of the
corresponding metatarsal bone is removed; and the wound is usually left open to heal.
This sort of operation is performed frequently for foot infections in patients with diabetes.
A partial foot amputation through the metatarsal bones is called transmetatarsal (TM)
amputation.
A Gangrene Foot….
Transmetatarsal (TM) amputation
Types (Levels) of Amputations
Major amputations are amputations where part of the leg is removed.
These are usually:
below the knee, called transtibial (TT) amputation, or
above the knee, called transfemoral (TF) amputation.
Occasionally an amputation of just the foot can be performed with a cut through the ankle
joint.
Below the knee operation (transtibial amuptation), the bone in the lower leg (tibia) is
divided about 12-15 cm below the knee joint. This produces a good size stump to which a
prosthesis can be fitted.
BELOW KNEE AMPUTATION DUE TO ISCHEMIA NECROSIS
Learn more about Diabetic Foot Care with this video presentation….
What can you do to control your blood sugar?
1. Diet Therapy
* Avoid simple sugars like cakes and chocolates. Instead have complex carbohydrated
like rice, pasta, cereals and fresh fruits.
* Do not skip or delay meals. It causes fluctuations in blood sugar levels.
* Eat more fiber-rich foods like vegetables.
* Cut down on salt.
* Avoid alcohol. Dietary guidelines recommend no more than two drinks for men and no
more than one drink per day for women.

9. 2. Exercise
Regular exercise is an important part of diabetes control.
Daily exercise . . .
* Improves cardiovascular fitness
* Helps insulin to work better and lower blood sugar
* Lowers blood pressure and cholesterol levels
* Reduces body fat and controls body weight
Exercise at least 3 time a week for ate least 30 minutes each session. Always carry quick
sugar sources like candy or softdrink to avoid hypoglycemia (low blood sugar) during
and after exercise.
3. Control your weight
If you are overweight or obese, start weight reduction by diet and exercise. This improves
your cardiovascular risk profile.
* It lowers your blood sugar
* It improves your lipid profile
* It improves your blood pressure control
4. Quit smoking.
Smoking is harmful to your health.
5. Maintain a normal blood pressure.
Since having hypertension puts a person at high risk of cardiovascular disease, especially
if it is associated with diabetes, reliable BP monitoring and control is recommended.
There are drug therapies using oral hypoglycemic agents. Your doctor can prescribe one
or two agent, depending on which is appropriate for you.
1. Sulfonylurea – Glibenclamide, Gliclazide, Glipizide, Glimepiride, Repaglinide
2. Biguanide – Metformin
3. Alpha-glucosidase Inhibitors – Acarbose
4. Thiazolidindione – Troglitazone, Rosiglitazone, Proglitazone.
Insulin Therapy….

10. Insulin preparation vary according to four main characteristics: time course of action,
concentration, species (source), and manufacturer.
Time course – Insulin may be grouped into 3 main categories based on onset, peak,
duration of action.
Concentration – Most common concentration of insulin in the united states is U-100.
Means that there are 100 units of insulin per 1 cubic centimeter. 100 units of U-100 is 1
ml, 50 units of U-100 is 1/2ml.
Species – Derived from pancreas of cows and pigs and conversion of this insulin to
human insulin.
Manufacturer – Lilly human insulin – “Humulin” and Novo Nordisk human insulin –
“Novolin”
Insulin Therapy….
Learn more about Insulin Preparation and Injecting Insulin with this video
presentation….
Remember
If you have the classic symptoms of diabetes:
* See your doctor for blood sugar testing
* Start dieting
* Eat plenty of vegetables
* Avoid sweets such as chocolates and cakes
* Cut down on fatty foods
* Exercise regularly
* If you are obese, try to lose some weight
* Avoid alcohol drinking and stop smoking
* If you are hypertensive, consult your doctor for advice and management
DOH Calendar of Events, July 2008
> National Blood Donors Month
> Nutrition Month
> National Disaster Consciousness Week (1-7)
> World Population Day (11)
> National Disability Prevention and Rehabilitation Week (14-20)
> National Diabetes Awareness Week (14-20)
DOH Calendar of Events, November 2008

11. > Cancer Pain Awareness Month
> Filariasis Awareness Month
> Malaria Awareness Month
> Traditional and Alternative Health Care Month
> Chronic Obstructive Pulmonary Disease (COPD)
Awareness Week (3-9)
> National Skin Disease Detection and Prevention Week (10-16)
> National Food Fortification Day (7)
> Deaf Awareness Week (10-16)
> World Diabetes Day (14)
> Drug Abuse Prevention and Control Week (17-23)
> Population and Development Week (23-29)
Doctor’s View about Diabetes Mellitus 1 & 2 thru video presentations….