Diabetus mellitus

1. RELIANCE INSTITUTE OF NURSING
TOPIC
PRESENTED BY :-
MR. ROMAN BAJRANG
BASIC BS.C NURSING 2ND YEAR
RELIANCE INSTITUTE OF
NURSING LIMTAR DHAMTRI

2. Diabetes mellitus
INTRODUCTION:-
Diabetes Mellitus is a heterogeneous group of disorder
characterized by glucose intolerance. It is a disease caused by an imbalance
between insulin supply and insulin demand. In Diabetes Mellitus, either there is
not enough insulin or the insulin that is produced is ineffective resulting in high
blood glucose levels.
Diabetes Mellitus also causes disturbances of protein and
fat metabolism. These abnormalities are associated with micro vascular, macro
vascular and neuropathic changes.
There are two main types of Diabetes Mellitus
1.Insulin Dependent 2.NonInsulin Dependent
Diabetes Mellitus Diabetes Mellitus
3 .Gestational diabetes. 4. Other types
Diabetes Mellitus is a group of metabolic disease
characterized by hyperglycemia resulting from defect in insulin secretion,
insulin action as both. The basis of the abnormalities in carbohydrate, protein
and fat metabolism in diabetes is the deficient action of insulin on the target
tissues of skeletal muscle, adipose tissue and the liver, uncontrolled diabetes
mellitus may result in long term damage, dysfunction and failure of various
organ. Diabetes cannot be cured, but it can be controlled.

3. Elliott Joslin, MD 47, who is regarded as the father of diabetes
care, stated that “Diabetes is a serious disease and deserves the best effort of
doctor and patient from beginning to end.”
By its very nature, Diabetes Mellitus can be significantly
influenced by daily self care. No other disease demands so much of the patient’s
own self Knowledge and skill .Thus the professional nurse has the challenge
and responsibilities of helping patients gain the knowledge skill, and attitude
necessary for self care.
Diabetes Mellitus is a common chronic disease of adult
required continuing medical supervision and client self-care education;
however, depending on the type of diabetes and the age of the client, both client
needs and nursing care may vary greatly.
“Insulin, a hormone produced by the pancreas, controls the
level of glucose in the blood by regulating the production and storage of
glucose.
This lead to hyperglycemia, which may result in acute
metabolic complications such as diabetic ketoacidosis (DKA) and
hyperglycemic hyperosmlar non ketotic syndrome (HHNS).
INCIDENCE:-
Appropriate 12 to 14 million Americans have diabetes and
approximately 6 million of these are diagnosed About 600,000 new cases of
diabetes are reported in the united states each year.
Diabetes, with its complications is the fourth leading causes
of death by disease in the United States. 1, 60,000 clients will die from diabetes
mellitus and its complication this year. Even when diabetes does not kill, it can
produce major permanent disabilities.

4. In the United States, primarily because of the widespread
cardiovascular effect that results in atherosclerosis, coronary artery disease and
stroke people with diabetes are two to four times more likely to have a stroke
them people who do not have diabetes. Diabetes is the leading cause of end
stage renal disease.
DEFINITION:-
1. According to Phipps, Monahan textbook of Medical Surgical
Nursing:
“Diabetes mellitus is a group of metabolic disease characterized
by hyperglycemia resulting from defects in insulin secretion action orboth.”
2. According to lumen textbook ofmedical Surgical Nursing:-
“Diabetes Mellitus is a heterogeneous group of disorder
characterized by glucose intolerance. It is a disease caused by an imbalance
between insulin supply and insulin demand”.
3. According to Brunner and Suddharth:-
“Diabetes Mellitus is a group of metabolic disease characterized by
increased level of glucose in the blood (hyperglycemia) resulting, insulin action
or both”.
ANATOMY AND PHYSIOLOGY:-
PANCREAS:- The pancreas is a retroperitoneal gland that is about 12 to 15
cm. long and 2.5 cm thick, lies posterior to the greater curvature of the stomach.
The pancreas is consist of head, body, and tail and is usually connected to the
duodenum by two ducts. Pancreatic juice is secreted by exocrine cell into small
duct that ultimately unite to form two larger ducts:

5. 1. The pancreatic duct and
2. The assessor duct.
The pancreatic duct is the larger of two ducts. In most people, the pancreatic
duct join the common bile duct from the liver and gallbladder and enters the
duodenum as a dilated common duct called hepatopancreatic ampulla.
The pancreas is made up small clusters of glandular epithelial cells.
About 99% of the clusters, called acini and the remaining 1% of the cluster,
called pancreatic islet (islet of langerhans), form endocrine portion of pancreas,
these cells are secrete the hormones:
α cells – glucagon
β cell -- insulin
δ cell -- somatostatin
Ƒ cell – pancreatic polypeptide.
Each day pancreas produce 1200 to 1500ml of pancreatic juice, a clear
colorless liquid consisting mostly water, some salt, sodium bicarbonate gives
pancreatic juice a slightly alkaline Ph7.1-8.2

6. ETIOLOGY: -
the main etiologies are:
Insulin Dependent Diabetes Mellitus –
1. Genetic factor
2. Environmental factor – Environmental factor have a role in the
development of diabetes, because the highest incidence of new cases of
Insulin Dependent Diabetes Mellitus occur during seasonal variations.
3. Injection with certain viruses and organism attached the islet cells of the
pancreas.
4. There is some autoimmune response in the development of Insulin
Dependent Diabetes Mellitus. Apparently some trigger causes the body to
develop islet cell antibodies and anti insulin antibodies.
Non Insulin DependentDiabetes Mellitus:-
1. Heredity
2. Obesity – overweight clients require more insulin for metabolizing the
food they eat. Hyperglycemia develops when the pancreas cannot secret
enough insulin to match the body’s need when the number of insulin
receptors site is decreased or altered.
3. Increase age – Increase age may also be a risk because the pancreas
becomes sluggish with age in client who is already predisposed to
diabetes.
3.Gestational Diabetes Causes
When you eat, your pancreas releases insulin, a hormone that helps move a sugar called
glucose from your blood to your cells, which use it for energy.
During pregnancy, your placenta makes hormones that cause glucose to build up in
your blood. Usually, your pancreas can send out enough insulin to handle it. But if your body
can’t make enough insulin or stops using insulin like it should, your blood sugar levels rise,
and you get gestational diabetes.

7. RISK FACTOR:- The main risk factors are:
o Family history- family history of diabetes mellitus
o Obese
o Suffer from excessive thirst, hunger, urination and weight loss
o Has a family history of diabetes
o Over the age of 40 years.
PATHOPHYSIOLGY
Due to etiological factor
↓
The production of insulin is decrease
↓
It leads to imbalance between insulin supply and insulin demand
↓
Resulting in increase glucose production and decrease glucose utilization
Intracellular hypoglycemia extracellular hypoglycemia
↓ ↓
Glucogenesis and gluconeogenesis blood glucose > renal threshold
↓ ↓
Breakdown of fats glucoseuria urine has a high SG
↓ ↓
High levels ofketones osmotic diuretic
↓ -Polyuria
Diabetic ketoacidosis -Polydipsia
-hypocalcaemia
-hyponatraemia

8. TYPES:-
There are two main types of diabetes mellitus
1. Insulin dependent diabetes mellitus 2.non insulin dependent diabetes
Mellitus
3 .Gestational diabetes. 4. Other types
Insulin dependent diabetes mellitus (type 1 diabetes
mellitus):-
It is the result of destruction of the beta cell of the islet of langerhans in the
pancreas, the only cell in the body that makes insulin. Where beta cell
destroyed, insulin is no longer produced.
Although type 1 diabetes mellitus may be classified as either an
autoimmune or idiopathic disorder, it cause the body to develop islet cell
antibiotic and anti insulin anti bodies, these antibodies attack the beta cell of the
pancreas and also the insulin molecule themselves.
Non Insulin dependent diabetes mellitus (type 2
diabetes mellitus):-
Virus and human leukocyte antigen do not appear to play a role in
the development of non insulin dependents diabetes mellitus. Heredity and
obesity is one of the most important determinants for the development of non
insulin dependent diabetes mellitus.

9. .Gestational diabetes
It is defined as carbohydrate intolerance resulting in hyperglycemia of variable
severity, with its onset or first recognition during pregnancy. This definition is
appropriate whether or not insulin is used for treatment or the diabetes persists
after pregnancy.
. Other types
Pre-diabetes indicates a condition that occurs when a person's blood
glucose levels are higher than normal but not high enough for a diagnosis
of type 2 diabetes. Genetic mutations (autosomal or mitochondrial) can
lead to defects in beta cell function. Abnormal insulin action may also have
been genetically determined in some cases. Any disease that causes
extensive damage to the pancreas may lead to diabetes (for example,
chronic pancreatitis and cystic fibrosis). Diseases associated with excessive
secretion of insulin-antagonistic hormones can cause diabetes (which is
typically resolved once the hormone excess is removed). Many drugs
impair insulin secretion and some toxins damage pancreatic beta cells.
CLINICAL MANIFESTATION:-
The main cardial sign of the diabetes mellitus;
 Polyuria: - because of hyperglycemia hyperosmolarity occur, resulting
increased blood volume, increased renal blood flow, and the
hyperglycemia act as an osmotic diuretic resulting increasing urine
output.

10.  Polydipsia: - Polyuria cause dehydration, the mouth become dry and
thirst sensor are activated causing the person to drink increase amount of
fluid.
 Glucoseuria: - glucose is excreted in urine, a condition is called
glucoseuria.
 Polyphagia: - because glucose cannot enter the cell without insulin,
energy production decrease it stimulate hunger, and the person eat more
food.
 Weight loss: - weight loss occurs in diabetes mellitus.
The client with insulin dependent diabetes mellitus usually present
with cardial sign and symptom already has complications.
Clint with non insulin dependent diabetes mellitus may also
develop the cardial sign and symptoms usually develop more slowly in non
insulin dependent diabetes mellitus because many of these clients are elderly
and may not recognized the abnormal thirst or frequent urination as abnormal
for their age. More commonly, they may only experience visual blurring,
neuropathic complication or infections.
. Other symptoms include: -
 Fatigue
 Weakness
 Sudden vision changes
 Tingling or numbness in hands or feet.
 Dry skin
 Skin lesions or wounds that are slow to heal & recurrent
infections
The onset of type 1 diabetes may also be associated with
sudden weight loss or nausea, vomiting or abdominal pains,
if DKA has developed.

11. DIAGNOSTIC EVALUATION:-
Assessment &Diagnosis
Assessment
History
 Symptoms should be related to the diagnosis of diabetes:
 Symptoms of hyperglycaemia.
 Symptoms of hypoglycaemia.
 Its frequency, timing, severity & resolution
 Results of blood glucose monitoring.
 Status symptoms & management of chronic complications of
diabetes:
 Eye, kidney, nerve, genitourinary & sexual, bladder &
gastrointestinal.
 Cardiac, peripheral vascular, foot complications
associated with diabetes.
 Compliance with prescribed dietary management plan.
 Adherence to prescribed exercise regimen.
 Compliance with prescribed pharmacologic treatment.
 Use of tobacco, alcohol & prescribed & over the counter
medications/drugs.
 Lifestyle, culture, psychosocial & economic factors that may
affect diabetes treatment.
Physical examination
 Blood pressure (sitting & standing to detect orthostatic
changes).
 Body mass index
 Fundoscopic examination
 Foot examination (lesion, sign of infection, pulse).
 Skin examination (lesions & insulin injection sites).
 Neurologic examination
 Vibratory & sensory examination using
monofilament.
 Deep tendon reflexes.
 Oral examination.

12. Bloodglucose (blood sugar):- A blood sample is taken for determination of
glucose level.
1)Fasting blood sugar- For FBS test, the client may not eat for 4 hrs,
but water intake may continue. If the client is being infused with a
dextrose intravenous solution. Average normal value for adult are 70 to
110mg/100ml but vary with age. As a general rule in an adult, a fasting
blood sugar level over 140 mg for two to their consecution test may
indicate diabetes.
2)Random blood glucose- For random blood glucose, blood can be
drawn at any time throughout the day, a random blood glucose level of
200mg/dl higher in persons who have symptoms of diabetes mellitus.
3)Oral glucose tolerance test- OGTT is a most sensitive test for
diagnosing diabetes.
4)Urine and serum Keaton test. urine methods measure
either acetoacetate or acetoacetate and acetone but do not
usually detect beta-hydroxybutyrate. Blood ketones may be
measured in a laboratory or with a handheld monitor. The
laboratory test uses serum, the liquid portion of the blood, and
typically measures acetoacetate.
5) HgbA1c
6) Fasting lipid profile
7) Test for microalbiminuria
8) Serum creatinine level
9) Urinalysis
10) Electrocardiogram

13. MANAGEMENT:-
MEDICAL MANAGEMENT:-
The main goal of treatment in no normal insulin activity and blood
the therapeutic goal within each type of diabetes is to achieve normal blood
glucose without hypoglycemia and without seriously disrupting the patient’s
usual activities. There are five component of management for diabetes;
nutrition, exercise, monitoring, pharmacological therapy and education.
 Primary treatment of type 1 diabetes is insulin.
 Primary treatment of type 2 diabetes is control of weight loss.
 Exercise is important in enhancing the effectiveness of insulin.
 Use oral hypoglycemia agent if client and exercise are not successful in
controlling blood glucose level. Insulin may be used in acute situations.
 Because treatment varies throughout course because of change in life
style and physical and emotional status as well as advance in therapy,
continuously assess and modify treatment plan as well as daily
adjustment in therapy.

14. S.
N.
DRUG
NAME
ACTION DOSES ROUTE INDICATION CONTRA-
INDICATION
NSG.
RESPONSIBI
LITY
1.
2.
3.
Acarbose
Glipizide
Pioglita-
zone
An alpha
glucosidase
inhibitor that
delay glucose
absorption
and digesion
of
carbohydrate.
A second
generation
sulfonylurea
that promote
the release of
insulin from
beta cells of
the pancreas
and increase
insulin
sensitivity.
An
antidiabetic
that improves
target cell
response to
insulin
without
increasing
pancreatic
insulin
secretion.
25 mg
10mg
30mg
PO
PO
PO
Diabetic
Mellitus
Diabetic
Mellitus
Diabetic
mellitus,
combination
therapy
Chronic
intestinal
disease,
cirrhosis,
colonic
ulceration,
hypersensitivit
y
Diabetic
ketoacidosis
with or without
coma, type 1
diabetes
mellitus.
Active hepatic
disease,
diabetic
ketoacidosis,
increase serum
transaminase
level.
To check
blood
glucose level,
Advice the
patient not
to skip or
delay meals.
Monitor the
patient blood
glucose level
& food
intake.
Make sure
the patient is
aware of the
typical sign
& symptoms
of hypo-
glycemia
&hyperglyce
mia.
Check
patient’s
hepatic
enzyme
level.
Instruct the
patient to
carry candy
sugar
packets, or
chest pain.

15. PHARMACOLOGIC MANAGEMENT:-
Oral hypoglycemic agent: - some client with NIDDM may require oral
hypoglycemic agent for lowering blood glucose level. It is not insulin.
Action: they lower the blood glucose in part by stimulating the pancreatic beta
cell to release insulin.
The average candidate for the oral hypoglycemic agents
= is over the age of 40 years.
= has no history of ketosis.
= is not pregnant
= is on less than 40 unit of insulin per day
= has mild to moderate symptoms of hyperglycemia
Contraindicated: - in clients with IDDM, pregnant or breastfeeding women,
children, surgery client and those with allergy client to sulfa.
Side effect:- hypoglycemia, especially in the elderly.
INSULIN THERAPY:-
All clients with IDDM must inject insulin daily to survive. Some
client with NIDDM may require insulin if diet, exercise and oral hypoglycemic
agent are infective.
Insulin lowers blood glucose by:
a) Promoting the transport of glucose into the cell and,
b) Inhibiting the conversion of glycogen and amino acid to glucose.
There are several types of insulin
 Rapid acting
 Intermediate acting
 Long acting
The absorption and duration of insulin varied by anatomic site. Insulin injected
into the abdomen is absorbed fastest and as a consequence, the duration is
shortest. Moving the injection site to the arm, leg or buttock, progressively slow
absorption and lengthens duration.

16. Insulin sources:- there are three sources of insulin beef, pork and human.
Insulin dosage:- insulin dosage varies greatly.
Requirement:- the insulin requirement usually increase when a client
 Is seriously ill
 Develop an infection
 Undergoes surgery
 Suffer trauma
 Going through puberty
Starting dose determined 0.5-1unit/kg body weight/day.
Insulin pump: - small partable pump for the continuous administration of
regular insulin are now some time used. Insulin pump often improved blood
glucose control by mean of continuous subcutaneous insulin infusion.
Complication of insulin pump:-
 Local infection at the injection site
 Hypoglycemia due to error in calculating insulin dosage or to punp
malfunction
 Diabetic ketoacidosis due to injection of insufficient insulin to meet
regular or increase metabolic need or to pump malfunction.
SURGICAL MANAGEMENT:-
Pancreas transplantation:- if the patient is unable to control blood sugar
levels with conventional treatment a pancreas transplant may be considered,
with a successful pancreas transplant, patient would no longer need insulin
therapy.
NURSING MANAGEMENT:-
Nursing assessment
1. Obtain a history of current problem, family history, and general health
history.

17.  Has the patient experienced Polyuria, Polydipsia, Polyphagia, and other
symptoms?
 Number of years since diagnosis of diabetes.
 Family members diagnosed with diabetes, their subsequent treatment, and
complications
2. Perform a review of system and physical examination to assess for sign
and symptoms of diabetes, general health of patients and presence of
complications.
 General: recent weight loss or gain, increased fatigue, tiredness, anxiety
 Skin: skin lesion, infection, dehydration, evidence of poor wound
healing
 Eyes: changes in vision floaters, halos, blurred vision, dry or burning
eyes, cataracts, glaucoma.

18. NURSING CARE PLAN-

19. S.NO. NURSING
DIAGNOSIS
NURSING
GOAL
INTERVENTION
1.
2.
3.
Fluid volume
deficient related
to osmotic
diuretic dieresis
from
hyperglycemia
Altered nutrition
related to
imbalance of
insulin, food and
physical activity.
Activity
intolerance
related to poor
glucose control
To maintain
fluid volume
Improving
nutrition
intake
Maintaining
activity
within
normal
range.
1) Monitoring and record intake
and output and daily weight. Note
urine specific gravity.
2) Monitor temperature, skin
color and moisture.
3) Assess skin turgor and mucous
membrane for sign of dehydration
4) Encourage the patient to
increase fluid intake.
1) The patient’s nutritional intake
is monitored carefully along with
blood glucose, urine ketones,
daily weight and weight history of
the patient.
2) Assess the patient for the sign
of hyperglycemia.
3) Discuss the importance of
consuming nutritional diet.
4) Advice patient on the important
of an individualized meal plan in
meeting weight loss and
incentives to assist in achieving
them.
1) Advise patient to assess blood
glucose level before and after
strenuous exercise.
2) Instruct patient to plan
exercises on a regular basis each
day.
3) Instruct patient to avoid
exercise whenever blood glucose
levels exceed 250mg/day and
urine ketones are presents.
4) Encourage patient to eat a
carbohydrate snack before

20. exercising to avoid hypoglycemia.
RATIONAL EVALUATION
1) Provide ongoing estimate of volume
replacement needs, kidney function and
effectiveness of therapy.
2) Fever, chill, and diaphoresis are common
with infectious process; fever with flushed,
1 dry skin may reflect dehydration.
3) Dry skin and mucous membrane is sign
of dehydration.
4) To place fluid loss and prevent
dehydration.
1) An appropriate caloric intake allows the
patient to achieve and maintain the desired
body weight.
2) It results when body inadequate insulin is
present to use glucose.
3) The individual with type 1 diabetes
mellitus may need to increase calories to
gain weight once insulin is controlling
glucose level.
4) However, fat diets or diet plan that stress
one food group and eliminate another are
generally not recommended.
1) Exercise lowers the blood glucose level
by increasing the uptake of glucose by body
muscle and by improving insulin utilization.
2) Exercising at similar time each day also
helps prevent blood glucose fluctuation.
3) This indicates that insufficient insulin is
available and glycogen may be released
during exercise, further increase increasing
the serum glucose.
4) It helps to avoid hypoglycemia.
Patient should be able decrease
his or her blood glucose level
while maintaining acceptable
intake and output, vital signs,
fluid and electrolyte.
Patient experience adequate
calories or nutrition intake as
evidenced by achieving a
reasonable weight, resolution of
Polydipsia, Polyuria, Polyphagia,
and glucose levels within normal
range.
Exercise is important in helping
with weight control as well as
helping any medication or insulin
therapy to work more effectively.

21. S.NO. NURSING
DIAGNOSIS
NURSING
GOAL
INTERVENTION
4.
5.
Impaired skin
integrity related
to
Decreased
sensation and
circulation lower
extremities.
Ineffective
management of
therapeutic
regimen related to
lack of
knowledge of
adequate exercise
program, diet and
weight control.
maintain skin
integrity
Improving
knowledge
1) Assess feet and legs for skin
temperature, sensation, soft
tissue injuries, dryness, hammer
toe or bunion deformation, hair.
2) Maintain skin integrity by
protecting feet from breakdown.
3) Uses heal protectors, special
mattresses, foot cradles for
patients on bed rest.
4) Apply skin moisturizers to
maintain suppleness and prevent
cracking and fissures.
1) Review patient’s current level
of knowledge regarding disease
ability to care for self.
2) Encourage patient and family
participation in diabetic self care
regimen.
3) Assess adherence to diet
therapy, monitoring procedure,
medication
Treatment, and exercise regimen.
4) Demonstrate finger stick
glucose monitoring and
recording.

22. RATIONAL EVALUATION
Assessment provides baseline data for
better interventions.
Teaching should be initiated only if a
knowledge deficit exists.
Participation in diabetes self care regimen
helps to foster confidence.
Make sure patient has adequate
knowledge of diet, exercise, and
medication treatment.
Good blood glucose control depends on
knowledge of glucose levels and trends.
These interventions help in
promoting sensation and circulation
to lower extremities and maintain
skin integrity.
Patient state cause, prevention,
symptoms, and treatment of
hypoglycemia.
Patient demonstrate correct use of
glucose monitor or state how
monitor.

23. NUTRITIONAL MANAGEMENT:-
The dietary requirement for both type 1 and type 2 diabetes are critical
but for different reasons for both types, for type 1 diabetes diet is necessary to
be able to regulate dosage of insulin therapy. For type 2 diabetic diets is
important to manage the blood weight control. Modifying eating habit are
typically important steps toward reducing blood sugar level.
COMLICATION:-
Long term complication of diabetes develop gradually,
diabetes complication may be disabling or even life threatening. Possible
complication includes;
Cardiovascular disease:- diabetes dramatically increases the risk of various
cardiovascular problems, including coronary artery disease with chest pain,
heart attack, stroke and narrowing of arteries if have diabetes are more likely to
have heart disease or stroke.
Nerve damage (neuropathy):- excess sugar can injure the wall of the tiny
blood vessels (capillary) that nourish nerve, especially in the legs. It can cause
tingling, numbness, burring or pain that usually being tip of the toes. Damage to
the nerve related to digestion can cause problem with nausea, vomiting, diarrhea
or constipation.
Kidney damage (nephropathy):- diabetic can damage the delicate filtering
system it can lead kidney failure.
Eye damage: - diabetic can damage the blood vessels of the retina (diabetic
retinopathy), potentially lead to blindness.
Foot damage: - nerve damage in the feet or poor blood flow to the feet increase
the risk of various foot complication.
Skin and mouth complication:- diabetes may leave patient more susceptible to
skin problem including bacterial and fungal infection.

24. Brain problem: - recent research suggested that high blood sugar level may
increase the risk of Alzheimer’s disease in people who have type 2 diabetes
mellitus.
HEALTH EDUCATION:-
 Provide special equipment for instruction on diabetic survival skill (e.g.
Magnifying glass for insulin preparation or injection aid device for
insulin injection)
 Assist in identifying community resources consideration to financial and
physical limitations.
 Initial education address the importance of consistency in eating habits
the relationship of food and insulin and provision of individualized meal
plan.
 Teach patient with blood glucose level of more than 250mg/dl not to
being exercising until the urine ketones test is negative and blood glucose
level are close to normal.
 Advise all patients with diabetes to discuss an exercise program with their
physician.
 Provide initial training in SMBG techniques.
 Evaluate the technique of patient experienced in SMBG.
CONCLUSION:-
Diabetes Mellitus is a heterogeneous group of disaster characterized
by glucose intolerance. Diabetes Mellitus also causes disturbances of protein
and fat metabolism. These abnormalities are associated with micro vascular,
macro vascular and neuropathic changes. There are two main types of Diabetes
Mellitus; Insulin Dependent Diabetes Mellitus and Non Insulin Dependent
Diabetes Mellitus. In treatment include oral hypoglycemic agent and insulin
therapy, and the surgical management is pancreas transplantation. Long term
complication of diabetes develop gradually, diabetes complication may be

25. disabling or even life threatening. Possible complication includes; systemic
diseases.

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