DM

• Diabetes mellitus


  A group of diseases characterized by hyperglycemia (fasting plasma glucose level >100 mg/dL) and abnormalities in fat, carbohydrate, and protein metabolism that lead to microvascular, macrovascular, and neuropathic complications
• Classification of diabetes mellitus by pathologic cause

  • Type 1 diabetes (beta cell destruction, usually leading to absolute insulin deficiency)
  • Type 2 diabetes (The pancreas still maintains some capacity to produce and secrete insulin)
  • Other specific types (Genetic defects of beta cell function, Genetic defects in insulin action, Disease of the exocrine pancreas, Endocrinopathies)
  • Gestational Diabetes Mellitus
• Signs and symptoms of diabetes mellitus


  • weight gain or loss, Blurred vision/diabetic retinopathy, numbness or tingling of the extremities (paresthesia), loss of sensation, orthostatic hypotension, impotence, vaginal yeast (candidiasis) infections, difficulty in controlling urination (neurogenic bladder), Nonhealing ulcers of the lower extremities may indicate chronic vascular disease
• Treatment of diabetes mellitus


  • Balanced diet, Medical Nutrition Therapy (MNT), Insulin or oral antidiabetic therapy, Routine exercise, Good hygiene, Maintenance of an ideal body weight, Reduction of lipids and cholesterol, smoking cessation [including e-cigarettes], blood pressure control, influenza and pneumococcal vaccinations
• Nursing implications for patients with diabetes mellitus


  • Diet, Activity level, Blood or urine testing, Medication, Self-injection techniques, Prevention of complications, Illness management, Effective management of hypoglycemia or hyperglycemia
• Complications associated with diabetes mellitus


  • Cardiovascular disease, Peripheral vascular disease, Visual alterations, Renal disease, Infection, Neuropathies, Impotence, Hypertension
• Insulin


  A hormone produced in the beta cells of the pancreas, is a key regulator of metabolism. Insulin is required for the entry of glucose into skeletal and heart muscle and fat. It also plays a significant role in protein and lipid metabolism. It is not required for glucose transport into the brain, kidney, gastrointestinal, or liver tissue.
• Types of insulin


  • rapid-acting, short-acting, intermediate-acting, long-acting insulins
• Onset


  The time required for the medication to have an initial effect or action
• Peak


  When the insulin will have the maximum effect
• Duration


  How long the agent remains active in the body
• Storage of insulin


  • Refrigerator (not the freezer) until opened, Room temperature (68° to 75°F) until gone, Gently rolled in the palms of the hands (not shaken) to warm and resuspend the insulin, Discarded within 30 days after opening
• Premedication assessment for insulin


  • Confirm that a blood glucose level was recently measured and was acceptable for the individual patient, Confirm that the patient has had a level of activity reasonable for that patient and that the anticipated level of activity planned for the next several hours is balanced with the insulin dose, Confirm that the prescribed diet is being consumed as planned and that no changes in diet are anticipated in relation to insulin dosage over the next several hours
• Common and serious adverse effects of insulin


  • Metabolic: Hyperglycemia, Hypoglycemia, Immune system: Allergic reactions (Itching, Redness, swelling at the site of injection, Acute rashes/anaphylactic are rare symptoms), Lipodystrophies
• Treatment for adverse effects of insulin


  • Antihistamines, Epinephrine, Steroids
• Metformin


  A class of oral antihyperglycemic agents known as the biguanides. It reduces absorption of glucose from the small intestine, and increases insulin sensitivity, improving glucose uptake in peripheral muscle and adipose cells. Insulin must be present for metformin to be active, and therefore metformin is not effective in type 1 diabetes.
• Dosage and administration of metformin

  • PO: Immediate-release tablet or solution: Initial: 500 mg twice daily or 850 mg once daily; titrate in increments of 500 mg weekly or 850 mg every other week; may also titrate from 500 mg twice a day to 850 mg twice a day after 2 weeks, PO: Extended-release tablet: Initial: 500 to 1000 mg once daily; dosage may be increased by 500 mg weekly up to a maximum of 2500 mg/day
• Therapeutic Outcomes of Metformin


  1. Fewer long-term complications associated with poorly controlled type 2 diabetes mellitus
• Actions of Sulfonylurea Oral Hypoglycemic Agents


  The sulfonylureas lower blood glucose levels by stimulating the release of insulin from the beta cells of the pancreas. The sulfonylureas also diminish glucose production and metabolism of insulin by the liver
• Actions of Meglitinide Oral Hypoglycemic Agents


  They lower blood glucose levels by stimulating the release of insulin from the beta cells of the pancreas
• Actions of Thiazolidinedione Oral Antidiabetic Agents


  The TZDs lower blood glucose levels by increasing the sensitivity of muscle and fat tissue to insulin, allowing more glucose to enter the cells in the presence of insulin for metabolism. Unlike sulfonylureas or meglitinides, TZDs do not stimulate the release of insulin from the beta cells of the pancreas, but insulin must be present for these agents to work
• Drug interactions that may enhance hypoglycemic effects of Thiazolidinediones


  sulfonylureas, ethanol, androgens (e.g. methandrostenolone), warfarin, salicylates, sulfonamides (e.g., sulfamethoxazole-trimethoprim), fluoroquinolones (ciprofloxacin, levofloxacin, norfloxacin), and MAOIs
• Drug interactions that may decrease effects of Thiazolidinediones


  corticosteroids, phenothiazines, diuretics, oral contraceptives, thyroid replacement hormones, phenytoin, and lithium carbonate
• Drug interactions with Beta-adrenergic blocking agents


  Beta blockers (e.g., propranolol, nadolol, metoprolol, carvedilol) may induce hypoglycemia but may also mask many of the symptoms of hypoglycemia
• Actions of Alpha-Glucosidase Inhibitor Agents


  Acarbose and miglitol are classified as an antihyperglycemic agents. They are enzyme inhibitors that inhibit pancreatic alpha-amylase and gastrointestinal alpha-glucoside hydrolase enzymes used in the digestion of sugars. In patients with diabetes, this enzyme inhibition results in delayed glucose absorption and a lowering of postprandial hyperglycemia
• Alpha-Glucosidase Inhibitor Agents


  Acarbose, Precose, miglitol, Glyset
• Sodium-glucose cotransporter 2 inhibitors


  Block the secretion of the SGLT2 protein, dropping glucose reabsorption from 90% to less than 10%, causing the glucose to be excreted in the urine
• Glucagon


  A hormone secreted by the alpha cells of the pancreas that breaks down stored glycogen to glucose, resulting in elevated blood glucose levels