Mr. G, a 47-year-old businessman, was admitted to the hospital on September 27th at 11:05pm for diabetes mellitus, ischemic heart disease, hyperlipidemia, and hypertension. His medical history includes hypertension, diabetes, ischemic heart disease in 2008, and peripheral vascular disease in 2010. On examination, he had dry skin, flaky skin on his lower legs and feet, and an IV in his left hand. Lab tests showed elevated glucose, cholesterol, and kidney function. Imaging found an old heart attack and brain infarct. The patient's diabetes is managed through diet, exercise, oral medications, and possibly insulin therapy depending on his ability to control blood sugar levels.

3. PATIENT BIODATA
• Mr G
• M/47
• Businessman
• ∆ DM, IHD, hyperlipidemia, HPT
• Admission – 27/9/16 @
2305HRS
• Consultant – Dr M

4. PATIENT BIODATA
• Med History – HPT, DM, IHD (2008) &
peripheral vascular disease (2010)
• Surg History – Angioplasty (2008),
peripheral angiogram (2010)
• Family History – DM, HPT (mother)
• Allergic – Unknown
• Mode of Admission – Trolley

5. ASSESSMENT
• VITAL SIGN :
 Temperature – 37.4˚C
 Heart Rate – 98 bpm
 Respiration – 22 bpm
 Pain Score - 2/10
 DM - 12.7 mmol/L
 Weight – 67 kg

6. ACTIVITY DAILY LIVING
• C/O extreme fatigue, giddiness and loss of
appetite X 1/12 and SOB X 1/7.
• Conscious, anxious.
• Chest tightness & cough with whitish
phlegm
• Heavy smoker 10 years ago

7. ACTIVITIES DAILY LIVING
• Frequent urination
• Insomnia
• Ambulate with assistant
• Side rail

8. PHYSICAL EXAMINATION
• Dry skin
• Dry and flaky skin at both lower legs and
foots
• IV branula 18G at left hand
• Oxygen 2L nasal prong in progress

9.  17KS, Trop T, CE, CKMB
 ECG
 CT Brain
 ECHO
 CXR (PA)
 TDS glucometer
S/B Dr M at casualty at 2215Hrs :

11. PANCREAS HORMONES :
• INSULIN BY BETA CELLS
• GLUCAGON BY ALPHA CELLS

12. Insulin PRODUCTION
Pancreas produce insulin
according to the blood
glucose level

14. • Pancreas secretes 40-50 units
of insulin daily in two steps:
– Secreted at low levels during
fasting ( basal insulin secretion)
– Increased levels after eating
(prandial)
– An early burst of insulin occurs
within 10 minutes of eating
– Then proceeds with increasing
release as long as hyperglycemia
is present

15. Insulin
• Insulin allows glucose to move into
cells to make energy
• Inhibits glucagon activity

18. Diabetes mellitus (DM) is a group of diseases
characterized by high levels of blood glucose resulting
from defects in insulin production, insulin action, or
both.
The term diabetes mellitus describes a metabolic
disorder of multiple aetiology characterized by chronic
hyperglycaemia with disturbances of carbohydrate, fat
and protein metabolism resulting from defects in insulin
secretion, insulin action, or both.
The effects of diabetes mellitus include long–term
damage, dysfunction and failure of various organs.
What is diabetes?

19. Diabetes
• Diabetes describes a group of metabolic
diseases in which the person has high blood
glucose (blood sugar), either because insulin
production is inadequate, or because the body's
cells do not respond properly to insulin, or
both.

21. • Type 1 Diabetes Mellitus
• Type 2 Diabetes Mellitus
• Gestational Diabetes
TYPES OF DIABETES

23. Types
1.Type I
 formerly known as Insulin –
Dependent Diabetes Mellitus (IDDM)
Autoimmune (Islet cell antibodies)
•Early introduction of cow’s milk and
cereals
•Intake of medicine during pregnancy
•Indoor smoking of family members
destruction of beta cells of the
pancreas  little or no insulin
production
requires daily insulin admin.
 may occur at any age, usually appears
below age 15

24. • Type 1 Diabetes:Type 1
diabetes is usually
diagnosed in children
and young adults. Only
10% of people with
diabetes have this form
of the disease.
• In type 1 diabetes, the
body does not produce
insulin.

26. • Patients with type 1 diabetes will need to take
insulin injections for the rest of their life. They
must also ensure proper blood-glucose levels
by carrying out regular blood tests and
following a special diet.

28. 2. Type II
 formerly known as Non Insulin–Dependent
Diabetes Mellitus (NIDDM)
 probably caused by:
 disturbance in insulin reception in the
cells
  number of insulin receptors
 loss of beta cell responsiveness to
glucose leading to slow or  insulin
release by the pancreas
 occurs over age 40 but can occur in children
 common in overweight or obese
 w/ some circulating insulin present, often do
not require insulin

29. • Type 2 diabetes:
• The body does not produce enough insulin for
proper function, or the cells in the body do not
react to insulin.
Approximately 90% of all cases of diabetes
worldwide are of this type.

30. • Overweight and obese people have a
much higher risk of developing type 2
diabetes compared to those with a
healthy body weight.
• The risk of developing type 2 diabetes is
also greater as we get older.
• Men whose testosterone levels are low
have also been found to have a higher
risk of developing type 2 diabetes.

33. Gestational Diabetes
This type affects females during
pregnancy.
The majority of gestational diabetes
patients can control their diabetes with
exercise and diet. Undiagnosed or
uncontrolled gestational diabetes can
raise the risk of complications during
childbirth. The baby may be bigger than
he/she should be.

35. What causes diabetes?
• Diabetes causes vary depending on your genetic
makeup, family history, ethnicity, health and
environmental factors.
• There is no defined diabetes cause because the
causes of diabetes vary depending on the individual
and the type.

40. Who are at
risk? ?

41. Risk Factors
• Obesity
• Race
• History of CVD
• HPT
• Physical inactivity
• Familial history
• Polycystic Ovary Syndrome
• Gestational Diabetes
? ? ? ? ? ? ?

44. What happens if there is a problem
with the production of insulin?
• Glucose in blood is not able to go into
the cells.
• The cells can’t meet energy needs and
energy is tried to be provided from ‘fat’
and protein’.
• Using ‘fat’ as the energy source results
the increasing of keton in the body.

45. Physiology

47. The symptoms of
diabetes

48. • With the usage of protein as energy
source,the patient feels themselves tired and
sluggish.
• If blood glucose is to high,It is tried to be
thrown away by kidneys so the patients begin
to urinate so often.
• As a result, the patients feel thirsty and start
to drink a lot.
• On the other
hand,despite eating
so often and a lot,the
patients lose weight.

51. Fasting Plasma Glucose

52. Oral Glucose Tolerance Test
(OGTT)

53. Glycoselated Hemoglobin (HbA1c)
• HbA1c is a test that measures the
amount of glycated hemoglobin in your
blood. Glycated hemoglobin is a substance
in red blood cells that is formed when blood
sugar (glucose) attaches to hemoglobin.

54. (HbA1c)

55. Glycoselated Hemoglobin (HbA1c)
Immediate
past month
50%
2nd
month 25%
3rd
month 15%
4th
month 10%

56. Urinalysis
• Glycosuria
• Ketone bodies

57. Diagnostic Criteria
• Classic signs of
HYPERGLYSEMIA with CPG
≥200mg/dL
• OGTT ≥200mg/dL
• FPG ≥126mg/dL
• A1C ≥ 6.5%

59. • CKMB
- 45 (< 25 U/L)
• ESR
- 20 (0-15 mm/hr)
• White blood cell count
- 20.2 (4.3 – 10.5 10³/uL)
• Neutrophil
- 87.3% (40-75%)
• Lymphocyte
- 5.3% (20-45%
• Glucose
17KS, Trop T, CE, CKMB

60. • Glucose
- 13.9 (3.9 – 6.1mmol/L)
• Creatinine
- 134 (51 – 124umol/L)
• Urea
- 6.9 (2.0 – 6.8umol/L)
• Sodium
- 131 (135 – 155mmol/L)
17KS, Trop T, CE, CKMB

61. • Total cholesterol
- 7.2mmol/L (<5.2)
• Triglycerides
- 2.04mmol/L (<1.71)
• HDL cholesterol
- 1.05mmol/L (>1.42)
• LDL cholesterol
- 5.2mmol/L (<2.6)
• Chol/HDL Chol
- 6.8 (up to 4.0)
17KS, Trop T, CE, CKMB

62. • Protein, urine
- ++ (Negative)
• Glucose, urine
- Trace (Negative)
• Bacteria, urine
- Occasional (Nil)
Urine FEME

63. • Normal
CXR (PA)

64. • Old infarct of right occipital
region.
CT BRAIN

65. • Old ant/apical MI
ECG

66. • LV apical deterioration
• Moderate LVAD
ECHO

68. • The major components of the treatment of
diabetes are:
Management of DM

70. Diet is a basic part of management in every case.
Treatment cannot be effective unless adequate
attention is given to ensuring appropriate
nutrition.
Dietary treatment should aim at:
◦ ensuring weight control
◦ providing nutritional requirements
◦ allowing good glycaemic control with blood glucose
levels as close to normal as possible
◦ correcting any associated blood lipid abnormalities
Diet

71. Physical activity promotes weight reduction and
improves insulin sensitivity, thus lowering blood glucose
levels.
Together with dietary treatment, a programme of
regular physical activity and exercise should be
considered for each person. Such a programme must be
tailored to the individual’s health status and fitness.
People should, however, be educated about the
potential risk of hypoglycaemia and how to avoid it.
Exercise

73. • There are currently four classes of oral anti-
diabetic agents:
i. Biguanides
ii. Insulin Secretagogues – Sulphonylureas
iii. Insulin Secretagogues – Non-sulphonylureas
iv. α-glucosidase inhibitors
v. Thiazolidinediones (TZDs)
Oral Anti-Diabetic Agents

74. Oral Antidiabetic Agents

75. ORAL HYPOGLYCAEMIC
MEDICATIONS

76. Short-term use:
Acute illness, surgery, stress and emergencies
Pregnancy
Breast-feeding
Insulin may be used as initial therapy in type 2 diabetes
in marked hyperglycaemia
Severe metabolic decompensation (diabetic
ketoacidosis, hyperosmolar nonketotic coma, lactic
acidosis, severe hypertriglyceridaemia)
C. Insulin Therapy

77. Long-term use:
If targets have not been reached after optimal
dose of combination therapy, consider change
to multi-dose insulin therapy. When initiating
this,insulin secretagogues should be stopped
and insulin sensitisers e.g. Metformin or TZDs,
can be continued.
C. Insulin Therapy

78.  The majority of patients will require more than one daily injection if
good glycaemic control is to be achieved. However, a once-daily
injection of an intermediate acting preparation may be effectively used
in some patients.
 Twice-daily mixtures of short- and intermediate-acting insulin is a
commonly used regimen.
 In some cases, a mixture of short- and intermediate-acting insulin may
be given in the morning. Further doses of short-acting insulin are given
before lunch and the evening meal and an evening dose of intermediate-
acting insulin is given at bedtime.
 Other regimens based on the same principles may be used.
 A regimen of multiple injections of short-acting insulin before the main
meals, with an appropriate dose of an intermediate-acting insulin given
at bedtime, may be used, particularly when strict glycaemic control is
mandatory.
Insulin regimens

79. Overview of Insulin and Action

81. InsulinInsulin
injectioninjection
sitessites

83. Factors that influence the body’s need
for insulin
11 need : trauma, infection, fever, severe
psychological or physical stress, other illnesses
2.  need : active exercise

84. DRUGS DATE ORDERED
IV Nootropil 1gm TDS 27/9/16
Janumet (50/500) 1/1 BD 27/9/16
Diamicron MR 1/1 BD 27/9/16
IV Cefrex 1gm STAT & BD 27/9/16
Brilinta 11/11 STAT & 1/1 BD 27/9/16
Vasteral MR 1/1 BD 27/9/16
Vytorin (10/20) 1/1 ON 27/9/16
Tanakan 1/1 TDS 27/9/16
Bioquinol 1/1 TDS 27/9/16

85. Diabetes
Management
Algorithm

87. • Hypoglycemia
 low blood glucose (usually below
60mg/dl)
 results from too much insulin, not enough
food, and/or excessive physical activity
 may occur 1-3 hrs after regular insulin
injection

89. Management of Hypoglycemia
1.Give simple sugar orally if pt. is conscious and can
swallow – orange juice, candy, glucose tablets, lump
of sugar
2.Give Glucagon (SQ or IM) if pt. is unconscious or
cannot take sugar by mouth
3.As soon as pt. regains consciousness, he should
be given carbohydrate by mouth
4.If pt. does not respond to the above measures, he
is given 50 ml of 50% glucose I.V. or 1000 ml of 5%-
10% glucose in water I.V.

90. Preventing Hypoglycemic Reactions Due to Insulin
Instruct the pt. as follows:
1.Hypoglycemia may be prevented by maintaining regular
exercise, diet and insulin
2.Early symptoms of hypoglycemia should by recognized
and treated
3.Carry at all times some form of simple carbohydrate
(orange juice, sugar, candy)
4.Extra food should be taken before unusual physical
activity or prolonged periods of exercise
5.Between-meal and bedtime snacks may be necessary
to maintain a normal glucose level.

92. CHRONIC COMPLICATIONS OF DM
• Degenerative changes in the vascular system
– Undernourishment
– Atherosclerosis
• Neuropathy from:
– Vascular insufficiency
– Hyperglycemia
• Eye complications from anoxia
– Cataract
– Diabetic retinopathy
– Retinal detachment

93. • Nephropathy
– Damage & obliteration of capillaries supplying the
kidney
• Heart disease
– Mi from atherosclerosis
• Skin changes
– DIABETIC DERMOPATHY – HYPERPIGMENTED &
SCALY PRETIBIAL AREAS (acanthosis nigricans)
• Liver changes
– Enlargement & fatty infiltration
CHRONIC COMPLICATIONS OF DM

96. SOME COMPLİCATİONS LİNKED TO BADLY CONTROLLED
DİABETES:
 Eye complications - glaucoma, cataracts, diabetic retinopathy, and
some others.
 Foot complications - neuropathy, and sometimes gangrene which
may require that the foot be amputated
 Heart problems - heart disease when the blood supply to the heart
muscle is diminished
 Hypertension - common in people with diabetes, which can raise
the risk of kidney disease, eye problems, heart attack and stroke
 Mental health - uncontrolled diabetes raises the risk of suffering
from depression, anxiety and some other mental disorders
• Hearing loss - diabetes patients have a higher risk of developing
hearing problems
• Gastroparesis - the muscles of the stomach stop working properly
• Stroke - if blood pressure, cholesterol levels, and blood glucose
levels are not controlled, the risk of stroke increases significantly

97. D.K.A.
PATHOPHYSIOLOGY
NO INSULIN
NO INSULIN
MARKED HYPERGLYCEMIAMARKED HYPERGLYCEMIA
GLUCOSURIAGLUCOSURIA
WEIGHT
LOSS
WEIGHT
LOSS
OSMOTIC
DIURESIS
OSMOTIC
DIURESIS
POLYURIAPOLYURIA
CELLULAR
HUNGER
CELLULAR
HUNGER
POLYPHAGIAPOLYPHAGIA
POLYDIPSIAPOLYDIPSIA
LIPOLYSISLIPOLYSIS
OSMOTIC
DEHYDRATION
OSMOTIC
DEHYDRATION

98. D.K.A.
S/SX:
• S/SX OF DM +
• KETONURIA
• METABOLIC ACIDOSIS
• KUSSMAUL’S RESPIRATION
• ACETONE BREATH
• DHN
• FLUSHED FACE
• TACHYCARDIA
• CIRCULATORY COLLAPSE COMA DEATH

99. D.K.A.
MANAGEMENT:
• ADEQUATE VENTILATION
• FLUID REPLACEMENT
• INSULIN – RAPID ACTING
• ECG

101. GENERAL STRATEGY
• Assessment
• Analysis
• Planning and
Implementation/Intervention
• Evaluation and Ongoing monitoring
• Documentation

102. ASSESSMENT
• Primary and secondary
assessment
• Focused assessment
–Subjective data collection
–Objective data collection

103. Diabetes Mellitus
Nursing Process
• Assessment – Medicines, Allergies, Symptoms, Family
Hx
• Nursing Diagnosis- Anxiety and Fear, Altered
Nutrition, Pain, Fluid Volume Deficit
• Planning – Address the nursing diagnosis
• Implementation – Prevent complications, monitor
blood sugars, administer meds and diet, teach diet
and meds, Asess , Assess, Assess
• Evaluation- Goals, EOC’s

104. Risk for Injury Related to
Sensory Alterations
• Interventions and foot care practices:
–Cleanse and inspect the feet daily.
–Wear properly fitting shoes.
–Avoid walking barefoot.
–Trim toenails properly.
–Report nonhealing breaks in the skin.

105. Risk for Impaired Skin Integrity
Wound Care
• Wound environment
• Debridement
• Elimination of pressure on infected area
• Growth factors applied to wounds

106. Chronic Pain
• Interventions include:
–Maintenance of normal blood glucose levels
–Analgesics
–Capsaicin cream

107. Risk for Injury Related to Disturbed
Sensory Perception: Visual
• Interventions include:
–Blood glucose control
–Environmental management
• Incandescent lamp
• Coding objects
• Syringes with magnifiers
• Use of adaptive devices

108. Ineffective Tissue Perfusion: Renal
• Interventions include:
– Control of blood glucose levels
– Yearly evaluation of kidney function
– Control of blood pressure levels
– Prompt treatment of UTIs
– Avoidance of nephrotoxic drugs
– Diet therapy
– Fluid and electrolyte management

110. Health Teaching
• Assessing learning needs
• Assessing physical, cognitive, and emotional
limitations
• Explaining survival skills
• Counseling
• Psychosocial preparation
• Home care management
• Health care resources

111. 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
Self-Care