Seminar on Diabetes mellitus

1. DIABETES MELLITUS
By- RAHUL RANJAN

2. The pancreas
• The pancreas is an elongated, tapered organ located across the
back of the belly, behind the stomach.
• The pancreas is about 6 inches long and sits across the back of the
abdomen, behind the stomach.
• The head of the pancreas is on the right side of the abdomen and is
connected to the duodenum (the first section of the small intestine)
through a small tube called the pancreatic duct.

4. Cont..
• 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.
• Endocrine. The endocrine gland, which consists of the islets of
Langerhans, secretes hormones into the bloodstream.

6. INTRODUCTION
• Diabetes mellitus: diabetes—Passing through, Mellitus—sweet
• Hyperglycaemia: hyper—excessive glyc—glucose emia—in the blood
• The major sources of this glucose are absorption of ingested food in the
gastrointestinal (GI) tract and formation of glucose by the liver from food
substances.
• Long-term effects of hyperglycaemia contribute to macrovascular
complications (coronary artery disease, cerebrovascular disease, and
peripheral vascular disease), chronic microvascular complications (kidney
and eye disease), and neuropathic complications (diseases of the nerves).

7. DEFINITION
• Diabetes mellitus is a group of metabolic diseases
characterized by elevated levels of glucose in the blood
(hyperglycaemia) resulting from defects in insulin secretion,
insulin action, or both (American Diabetes Association [ADA].

8. • FIGURE: (A) Cell membrane in normal state, with insulin receptors and insulin to regulate glucose intake.
• (B) Cell membrane in type 1 diabetes: insulin not present, glucose remains outside of cell.
• (C) Cell membrane in type 2 diabetes: without insulin receptors, glucose remains outside cell.

10. EPIDEMIOLOGY
• Diabetes mellitus affects about 17 million people, 5.9 million of whom are undiagnosed..
• In the United States, diabetes is the leading cause of non-traumatic amputations,
blindness among working-age adults, and end-stage renal disease.
• Diabetes is the third leading cause of death by disease, primarily because of the high rate
of cardiovascular disease (myocardial infarction, stroke, and peripheral vascular disease)
among people with diabetes.
• Diabetes is a growing challenge in India with estimated 8.7% diabetic population in the
age group of 20 and 70 years.
• The CPR (Crude prevalence rate) in the urban areas of India is thought to be 9 per cent.
In rural areas, the prevalence is approximately 3 per cent of the total population.

13. RISK FACTORS
• Age ≥45 years
• Previously identified impaired fasting glucose or impaired glucose tolerance
• Hypertension (≥140/90 mm Hg)
• HDL cholesterol level ≤35 mg/dL (0.90 mmol/L) and/or triglyceride level ≥250 mg/dL (2.8
mmol/L)
• History of gestational diabetes or delivery of babies over 9 lbs
• Family history of diabetes (ie, parents or siblings with diabetes)
• Obesity (ie, ≥20% over desired body weight or BMI ≥27 kg/m2)
• Race/ethnicity (eg, African Americans, Hispanic Americans,
• Native Americans, Asian Americans, Pacific Islanders)

14. SIGNS AND SYMPTOMS OF DIABETES
• Classic symptoms of diabetes mellitus include polydipsia (excessive
thirst), polyuria (excessive urination), and polyphagia (excessive
hunger).
• Glucose is unable to enter the cells, the cells starve, causing hunger.
• The large amount of glucose in the blood causes an increase in serum
concentration, or osmolality.
• The renal tubules are unable to reabsorb all the excess glucose that is
filtered by the glomeruli, and glycosuria results.
• Large amounts of body water are required to excrete this glucose, causing
polyuria, nocturia, and dehydration.
• The increased osmolality and dehydration cause polydipsia.

15. Cont..
• High blood glucose may also cause fatigue, blurred vision, abdominal pain, and
headaches.
• Other symptoms include fatigue and weakness, sudden vision changes, tingling
or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to
heal, and 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.
• Presence of ketones in the urine (ketones are a byproduct of the breakdown of
muscle and fat that happens when there's not enough available insulin)
• Frequent infections, such as gums or skin infections and vaginal infections

16. PHYSIOLOGY
• Insulin is secreted by beta cells, which are one of four types of cells in the
islets of Langerhans in the pancreas
• Insulin is an anabolic, or storage, hormone. When a person eats a meal,
insulin secretion increases and moves glucose from the blood into muscle,
liver, and fat cells
• In those cells, insulin:
Transports and metabolizes glucose for energy
Stimulates storage of glucose in the liver and muscle (in the form of glycogen)
Signals the liver to stop the release of glucose
Enhances storage of dietary fat in adipose tissue
Accelerates transport of amino acids (derived from dietary protein) into cells

17. Cont..
• Insulin also inhibits the breakdown of stored glucose, protein, and fat. During
fasting periods (between meals and overnight), the pancreas continuously
releases a small amount of insulin (basal insulin)
• Another pancreatic hormone called glucagon (secreted by the alpha cells of the
islets of Langerhans) is released when blood glucose levels decrease and
stimulate the liver to release stored glucose.
• The insulin and the glucagon together maintain a constant level of glucose in the
blood by stimulating the release of glucose from the liver.
• Initially, the liver produces glucose through the breakdown of glycogen
(glycogenolysis). After 8 to 12 hours without food, the liver forms glucose from the
breakdown of noncarbohydrate substances, including amino acids
(gluconeogenesis).

18. CLASSIFICATION
Type 1 Diabetes
• Mellitus Type 1 diabetes (formerly called juvenile diabetes mellitus,
or IDDM) is caused by destruction of the beta cells in the islets of
Langerhans of the pancreas.
• When the beta cells are destroyed, they are unable to produce
insulin
• Only 5% to 10% of people with diabetes have type 1 diabetes
• The patient with type 1 diabetes is most often young and thin and is
prone to develop ketoacidosis

21. Cont..

22. Cont..
Type 2 Diabetes Mellitus
• Type 2 diabetes mellitus (formerly called adult-onset diabetes
mellitus, or NIDDM) tissues are resistant to insulin.
• Insulin is still made by the pancreas, but in inadequate amounts,
because the tissues are resistant to it, hyperglycaemia results.
• Glucagon levels may be elevated.
• Heredity is responsible for up to 90% of cases of type 2 diabetes.

24. Gestational Diabetes
• Gestational diabetes mellitus (GDM) may develop during pregnancy,
especially in women with risk factors for type 2 diabetes.
• The extra metabolic demands of pregnancy trigger the onset of diabetes.
• Blood glucose usually returns to normal after delivery, but the mother has
an increased risk for type 2 diabetes in the future.
• If the mother with GDM is overweight, she should be counseled that weight
loss and exercise will decrease her risk of later developing diabetes.

25. Prediabetes
• Prediabetes refers to blood glucose levels that are above normal but
do not meet the criteria for diagnosing diabetes.
• Prediabetes usually occurs prior to the onset of type 2 diabetes.
• It is diagnosed by evaluating glucose tolerance or fast ing glucose
levels (see tests of diabetes below).
• Individuals with prediabetes may be able to prevent the onset of
diabetes with weight loss and exercise.

26. Secondary diabetes
• Secondary diabetes may develop as a result of another chronic
illness that damages the islet cells, such as pancreatitis or
cystic fibrosis.
• Prolonged use of some drugs, such as steroid hormones,
phenytoin (Dilantin), thiazide diuretics, and thyroid hormone,
may also impair insulin action and raise blood glucose.

27. Criteria for the Diagnosis of Diabetes Mellitus
i. Symptoms of diabetes plus casual plasma glucose concentration equal to or
greater than 200 mg/dL (11.1 mmol/L). Casual is defined as any time of day
without regard to time since last meal. The classic symptoms of diabetes
include polyuria, polydipsia, and unexplained weight loss. or
ii. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L).
Fasting is defined as no caloric intake for at least 8 hours. or
iii. 2-hour postload glucose equal to or greater than 200 mg/dL (11.1 mmol/L)
during an oral glucose tolerance test. The test should be performed as
described by the World Health Organization, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water. In the absence of
unequivocal hyperglycemia with acute metabolic decompensation, these
criteria should be confirmed by repeat testing on a different day. The third
measure is not recommended for routine clinical use

28. Diagnostic Tests
FASTING PLASMA GLUCOSE
• According to the American Diabetes Association,3 a normal plasma
glucose level is less than 100 mg/dL, although different laboratories
may have slightly different normal values.
• When the fasting plasma glucose (drawn after at least 8 hours
without eating) is 126 mg/dL, diabetes is diagnosed. A second test
may be required if the first test is not clearly diagnostic. If the fasting
plasma glucose is between 100 and 125 mg/dL, the patient has
impaired fasting glucose (IFG).

29. Cont..
• CASUAL PLASMA GLUCOSE. Sometimes it is not feasible to check
a fasting plasma glucose. A casual plasma glucose (CPG) is
checked without regard to the last meal. Diabetes is diagnosed if the
CPG is 200 mg/dL, with symptoms of diabetes.
• ORAL GLUCOSE TOLERANCE TEST. Another test to diagnose
diabetes is the oral glucose tolerance test (OGTT). An OGTT
measures blood glucose at intervals after the patient drinks a
concentrated carbohydrate drink. Diabetes is

30. Cont..
• An abnormally high blood glucose level is the basic criterion for the
diabetes diagnosis.
• Fasting plasma glucose (FPG) levels of 126 mg/dL (7.0 mmol/L) or more
or random plasma glucose levels exceeding 200 mg/dL (11.1 mmol/L) on
more than one occasion are diagnostic of diabetes.
• The oral glucose tolerance test and the intravenous glucose tolerance test
are no longer recommended for routine clinical use.
• Plasma glucose values may be 10% to 15% higher than whole blood
values, which are obtained with finger sticks.

33. Cont..
• ADDITIONAL TESTS. Because diabetes affects so many body
systems, additional tests recommended for baseline data
include:
• A lipid profile, serum creatinine and urine micro albumin levels
to monitor kidney function, urinalysis, and electrocardiogram.

35. MANAGEMENT OF DIABETES
Goal of diabetic management
• The main goal of diabetes treatment is to normalize insulin
activity and blood glucose levels to reduce the development of
vascular and neuropathic complications.
• The therapeutic goal for diabetes management is to achieve
normal blood glucose levels (euglycemia) without
hypoglycaemia and without seriously disrupting the patient’s
usual lifestyle and activity.

36. Nutritional management
Goal
• Improving blood glucose and lipid levels
• Providing consistency in day to day food intake (in type 1
diabates)
• Facilitating weight management ( in type 2 diabates)
• Providing adequate nutrition for all stages of life

38. • Glycaemic Control
• Two primary techniques are used to assess a patient’s glycaemic control: Self-
monitoring of blood glucose (SMBG) and serum measurement of haemoglobin
A1c (HbA1c).
• Self-Monitoring of Blood Glucose
• It helps patients and physicians assess the effects of food, medications, stress,
and activity on blood glucose levels and make appropriate adjustments.
• The current American Diabetes Association (ADA) guidelines recommend that
patients with diabetes self-monitor their glucose at least three times per day.
• Those who use basal-bolus regimens should self-monitor before each meal and
at bedtime (4 times daily).
• Initially some patients require more frequent monitoring, including both pre-
prandial and postprandial readings.

39. Pharmacologic Treatment

40. Cont..

41. Sites of action of oral antidiabetic medications

42. Insulin therapy

43. Alternative methods of insulin delivery
• Insulin pens
• Jet injectors
• Insulin pumps
• Transplantation of pancreatic cells:
Transplantation of the whole pancreas or a
segment of the pancreas is being performed on a
limited population (mostly diabetic patients
receiving kidney transplantations simultaneously).

44. Complications of insulin therapy
• local allergic reactions
• Systemic allergic reactions
• Insulin lipodystrophy
• Insulin resistance

45. NURSING MANAGEMENT
• Nurses should provide accurate and up-to-date information
about the patient’s condition so that the healthcare team can
come up with appropriate interventions and management.

46. NURSING ASSESSMENT
• Assess the patient’s history.
• Assess physical condition.
• Assess the patient’s blood pressure while sitting and standing to
detect orthostatic changes.
• Assess the body mass index and visual acuity of the patient.
• Perform examination of foot, skin, nervous system and mouth.
• Laboratory examinations. HgbA1C, fasting blood glucose, lipid
profile, microalbuminuria test, serum creatinine level, urinalysis, and
ECG must be requested and performed.

47. Diagnoses
• The following are diagnoses observed from a patient with diabetes mellitus.
• Risk for unstable blood glucose level related to insulin resistance, impaired
insulin secretion, and destruction of beta cells.
• Risk for infection related to delayed healing of open wounds.
• Deficient knowledge related to unfamiliarity with information, lack of recall, or
misinterpretation.
• Risk for disturbed sensory perception related to endogenous chemical
alterations.
• Impaired skin integrity related to delayed wound healing.
• Ineffective peripheral tissue perfusion related to too much glucose in the
bloodstream

48. Nursing Priorities
• Restore fluid/electrolyte and acid-base balance.
• Correct/reverse metabolic abnormalities.
• Identify/assist with management of underlying cause/disease
process.
• Prevent complications.
• Provide information about disease process/prognosis, self-care, and
treatment needs.

49. Planning and Goals
• Achievement of goals is necessary to evaluate the effectiveness of the
therapy.
• Acknowledge factors that lead to unstable blood glucose.
• Maintain glucose in satisfactory range.
• Verbalize plan for modifying factors to prevent or minimize shifts in glucose
levels.
• Achieve timely wound healing.
• Identify interventions to prevent or reduce Risk for Infection.

50. Cont..
• Regain or maintain the usual level of cognition.
• Homeostasis achieved.
• Causative/precipitating factors corrected/controlled.
• Complications prevented/minimized.
• Disease process/prognosis, self-care needs, and therapeutic
regimen understood.
• Plan in place to meet needs after discharge.

51. Nursing Interventions
• The healthcare team must establish cooperation in implementing the following
interventions.
• Educate about home glucose monitoring. Discuss glucose monitoring at home
with the patient according to individual parameters to identify and manage
glucose variations.
• Review factors in glucose instability. Review client’s common situations that
contribute to glucose instability because there are multiple factors that can play a
role at any time like missing meals, infection, or other illnesses.
• Encourage client to read labels. The client must choose foods described as
having a low glycemic index, higher fiber, and low-fat content.

52. Cont..
• Discuss how client’s antidiabetic medications work. Educate client on the functions of
his or her medications because there are combinations of drugs that work in different
ways with different blood glucose control and side effects.
• Check viability of insulin. Emphasize the importance of checking expiration dates of
medications, inspecting insulin for cloudiness if it is normally clear, and monitoring proper
storage and preparation because these affect insulin absorbability.
• Review type of insulin used. Note the type of insulin to be administered together with
the method of delivery and time of administration. This affects timing of effects and
provides clues to potential timing of glucose instability.
• Check injection sites periodically. Insulin absorption can vary day to day in healthy
sites and is less absorbable in lipohypertrophic tissues.

53. Evaluation
• To check if the regimen or the interventions are effective, evaluation must be done
afterward.
• Evaluate client’s knowledge on factors that lead to an unstable blood glucose level.
• Evaluate the client’s level of blood glucose.
• Verbalized achievement of modifying factors that can prevent or minimize shifts in glucose
level.
• Achieved timely wound healing.
• Identified interventions that can prevent or reduce risk for infection.
• Evaluate maintenance of the usual level of cognition.

54. Discharge and Home Care Guidelines
• Patient empowerment is the focus of diabetes education.
• Patient education should address behavior change, self-efficacy,
and health beliefs
• Address any underlying factors that may affect diabetic control.
• Simplify the treatment regimen if it is difficult for the patient to follow.
• Adjust the treatment regimen to meet patient requests.

55. Cont..
• Establish as specific plan or contract with the patient with simple, measurable
goals.
• Provide positive reinforcement of self-care behaviors performed instead of
focusing on behaviors that were neglected.
• Encourage the patient to pursue life goals and interests, and discourage an
undue focus on diabetes.
• Educate client on wound care, insulin preparation, 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.
• Encourage participation in support groups with patients who have had diabetes
for many years as well for those who are newly diagnosed.

56. Acute Complications of Diabetes
• HYPOGLYCAEMIA (INSULIN REACTIONS)
• Hypoglycaemia (abnormally low blood glucose level) occurs when
the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3
mmol/L).
• It can be caused by too much insulin or oral hypoglycaemic agents,
too little food, or excessive physical activity. Hypoglycemia may
occur at any time of the day or night. It often occurs before meals,
especially if meals are delayed or snacks are omitted.

57. DIABETIC KETOACIDOSIS
• DKA is caused by an absence or markedly inadequate amount of
insulin. This deficit in available insulin results in disorders in the
metabolism of carbohydrate, protein, and fat. The three main clinical
features of DKA are:
• Hyperglycemia
• Dehydration and electrolyte loss
• Acidosis

58. HHNS (Hyperosmolar Hyperglycemic
Nonketotic Syndrome)
• Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious
condition most frequently seen in older persons. HHNS can happen to
people with either type 1 or type 2 diabetes that is not being controlled
properly, but it occurs more often in people with type 2. HHNS is usually
brought on by something else, such as an illness or infection.
• In HHNS, blood sugar levels rise, and body tries to get rid of the excess
sugar by passing it in tor urine.
• If HHNS continues, the severe dehydration will lead to seizures, coma and
eventually death. HHNS may take days or even weeks to develop.

60. Health education
1. Take care of your diabetes.
• Work with your health care team to keep your blood glucose level within a normal
range.
• 2. Inspect your feet every day.
• Look at your bare feet every day for cuts, blisters, red spots, and swelling.
• Use a mirror to check the bottoms of your feet or ask a family member for help if
you have trouble seeing.
• Check for changes in temperature.

61. Cont..
3. Wash your feet every day.
• Wash your feet in warm, not hot, water.
• Dry your feet well. Be sure to dry between the toes.
• Do not soak your feet.
• Do not check water temperature with your feet; use a thermometer or elbow.
4. Keep the skin soft and smooth.
• Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not
between your toes.

62. 5. Smooth corns and calluses gently.
• Use a pumice stone to smooth corns and calluses.
6. Trim your toenails each week or when needed.
• Trim your toenails straight across and file the edges with an emery board or nail
file.
7. Wear shoes and socks at all times.
• Never walk barefoot.
• Wear comfortable shoes that fit well and protect your feet.
• Feel inside your shoes before putting them on each time to make sure the lining
is smooth and there are no objects inside.

63. 8. Protect your feet from hot and cold.
• Wear shoes at the beach or on hot pavement.
• Wear socks at night if your feet get cold.
9. Keep the blood flowing to your feet.
• Put your feet up when sitting.
• Wiggle your toes and move your ankles up and down for 5 minutes,
2 or 3 times a day.
• Do not cross your legs for long periods of time.
• Do not smoke.

64. 10. Check with your doctor.
• Have your doctor check your bare feet and find out whether you are
likely to have serious foot problems. Remember that you may not feel
the pain of an injury.
• Call your doctor right away if a cut, sore, blister, or bruise on your
foot does not begin to heal after one day.
• Follow your doctor’s advice about foot care.
• Do not self-medicate or use home remedies or over-thecounter
agents to treat foot problems.

65. SUMMARY

66. CONCLUSION

67. Thank You!