MS-MIDTERM

• Diabetes Mellitus (DM)


  A chronic disorder of carbohydrate, fat and protein metabolism
• Diabetes Mellitus (DM)


  • It is due to inadequate insulin production or increased resistance to insulin
  • The cause of DM is unknown
• Predisposing factors to DM

  • Stress
  • Heredity
  • Obesity
  • Viral infections
  • Autoimmune disorders
  • Women who are multigravida with large babies
• Pathophysiology of Diabetes


  1. Insulin deficiency

  2. Hyperglycemia

  3. Increased blood osmolarity

  4. Glycosuria

  5. Polyuria

  6. Polydipsia

  7. Increased blood viscosity

  8. Infections

  9. Hyperlipidemia

  10. Atherosclerosis

  11. Neuropathy

  12. Ketonemia
• Type I Diabetes Mellitus

  • Also called Insulin Dependent Diabetes Mellitus (IDDM), Juvenile-onset DM, Brittle or unstable DM
  • Onset before 30 years of age
  • Absolute deficiency of insulin due to absence of Islet of Langerhans in the pancreas
  • Client is thin due to inability to obtain glucose from carbohydrates, so body breaks down fats and protein
  • Client is prone to diabetic ketoacidosis (DKA)
• Collaborative management for Type I DM

  • Diet
  • Activity and exercise
  • Insulin (always a component)
• Type II Diabetes Mellitus

  • Also called Non-Insulin Dependent Diabetes Mellitus (NIDDM), Maturity onset DM, Ketosis-resistant DM
  • Onset after age 30 years
  • Relative lack of insulin or resistance to the action of insulin, usually insulin is sufficient to stabilize fat and protein metabolism but not carbohydrate
  • Client is obese
  • Client is prone to hyperglycemic, hyperosmolar, non ketotic coma (HHNC)
• Collaborative management for Type II DM

  • Diet
  • Activity and exercise
  • Oral Hypoglycemic Agents (OHA) or Injectable Hypoglycemic Agents (IHA) if hypoglycemia is uncontrolled
  • Insulin in case of stress, surgery, infections and pregnancy
• A deficiency in insulin results in hyperglycemia
• Clinical manifestations of DM

  • Polyuria, polydipsia, polyphagia (3 Ps) (more common in Type I DM)
  • Weight loss (more common in Type I DM)
  • Blurred vision
  • Slow wound healing
  • Infections: pyorrhea, UTI, vasculitis, cellulitis, furuncles, carbuncles, vaginal infections
  • Weakness and paresthesia
  • Signs of inadequate circulation to the feet
  • Signs of accelerated atherosclerosis: renal, cerebral, cardiac, peripheral
• Macrovascular complications of DM

  • Coronary artery disease (CAD)
  • Cardiomyopathy
  • Hypertension (HTN)
  • Cerebrovascular disease (CVD)
  • Peripheral vascular diseases (PVD)
  • Infection
• Microvascular complications of DM

  • Retinopathy
  • Nephropathy
  • Neuropathy
• Collaborative management for DM

  • Diet: Low calorie, high fiber, 20% protein, 30% fats, 50% carbohydrates, complex carbohydrates preferred
  • Activity and exercise: Increases glucose uptake, lowers insulin requirements, helps achieve desirable body weight, maintains normal serum lipids
  • Medications: Oral Hypoglycemic Agents, Insulin
• Oral Hypoglycemic Agents


  • Sulfonylureas: Dymelor, Diabenese, Amaryl, Glucotrol, Diabeta, Micronase, Tolinase, Orinase
  • Non-sulfonylureas: Alpha Glucosidase Inhibitors (Precose, Glyset), Biguanide (Metformin), Meglitinide (Starlix, Prandin), Thiozolidinediones (Actos, Avandia)
• Advise the patient to wear a medic-alert bracelet
• Types of Insulin


  • Very Rapid-acting or Rapid-acting: Humalog, Novolog
  • Short-acting: Regular (Humulin R, Novolin R)
  • Intermediate-acting: NPH (Humulin N, Novolin N), Lente (Humulin L, Novolin L)
  • Long-acting: Ultralente (Humulin U), Insulin Glargine (Lantus)
  • Premixed: Humulin 70/30, Humulin 50/50, Lispro/Protamine 75/25
• Regular insulin is the only insulin that can be administered intravenously in the emergency treatment of diabetic ketoacidosis
• Factors that increase the hypoglycemic effects of insulin

  • Aspirin, alcohol, oral anticoagulants, oral hypoglycemic drugs, beta-adrenergic blockers, tricyclic antidepressants, tetracycline, MAOI's
• Factors that cause hyperglycemia

  • Glucocorticoids, thiazide diuretics, thyroid agents, oral contraceptives, estrogen
• Illness, infection, and stress can elevate blood glucose levels and the need for insulin. Insulin should not be withheld during these times as it can result in hyperglycemia and ketoacidosis
• The peak of action time of insulin is important because of the possibility of hypoglycemic reactions occurring at that time
• Common types of Insulin

  • Short-acting Insulin
  • Intermediate-Acting Insulin
  • Long-Acting Insulin
  • Premixed Insulin
• Short-acting Insulin


  • ONSET: 1/2 - 1 1/2 hrs
  • PEAK: 2-4 hrs
  • DURATION: 5-7 hrs
• Intermediate-Acting Insulin


  • ONSET: 1-2 hrs
  • PEAK: 6-14 hrs
  • DURATION: 24 hrs
• Long-Acting Insulin


  • ONSET: 6 hrs
  • PEAK: 18-24 hrs
  • DURATION: 24 hrs
• Premixed Insulin


  • ONSET: 1/2 - 1 hr
  • PEAK: 2-12 hrs
  • DURATION: 18-24 hrs
• The main route of insulin injection is subcutaneous. This promotes slower absorption and is less painful. There are lesser blood vessels and nerves in the subcutaneous areas.
• The main areas for insulin injections are the abdomen, arms (posterior surface), thighs (anterior surface), and buttocks.
• Administer insulin at 90°L. Most insulin syringes have needle gauge 27 to 29, that is about 1/2 inch long.
• Do not massage injection site to prevent rapid absorption. Rapid absorption of insulin may cause hypoglycemia.
• Injections should be 1/2 inch apart within the anatomical area. Finish all sites in one anatomical area before going to another area.
• To prevent lipodystrophy (hard fatty masses in the subcutaneous layers)

  1. Systematic rotation of the site of injection

  2. Administer insulin at room temperature
• Gently roll vial in between the palms to redistribute insulin particles. Do not shake the vial; bubbles make it difficult to aspirate exact amount.
• Storing Insulin


  • Prefilled insulin syringes should be kept in the refrigerator. These will be potent for 7 days (1 week)
  • If a vial of insulin will be used up in 30 days (1 month), it may be kept at room temperature
  • Avoid exposing insulin to extremes of temperature
  • Insulin should not be frozen or kept in direct sunlight or a hot car
• Regular insulin may be mixed with any other type of insulin.
• Insulin zinc suspensions (intermediate-acting) may be mixed only with each other and regular insulin; not with other types of insulin.
• To mix insulins


  1. Introduce air into the vial of intermediate-acting insulin (e.g. NPH)

  2. Introduce air into the vial of regular insulin, and draw up the insulin

  3. Draw up the intermediate-acting insulin (NPH)
• Administer a mixed dose of insulin within 5 to 15 minutes of preparation; after this time the regular insulin binds with the NPH insulin and its action is reduced.
• Complications of insulin therapy

  • Local allergic reaction
  • Insulin Lipodystrophy
  • Insulin Resistance
  • Dawn Phenomenon
  • Somogyi Phenomenon
  • Insulin Waning
• Local allergic reaction


  Redness, swelling, tenderness and induration or a wheal at the site of injection may occur 1 to 2 hours after administration