Saint Paul University Philippines

School of Health Sciences

Graduate School

DIABETES MELLITUS TYPE 2

A Case Colloquium

Presented By:

Jiselmari Altheryn Bulan

Jellico Bryan Cabatotan

In Partial Fulfillment

of the Requirements for the Degree

Master of Science in Nursing

3rd Semester School Year 2016-2017

March 2017

INTRODUCTION
Purpose of the Study:

The purpose of this study is to enhance Nurses knowledge regarding

Diabetes Mellitus type 2 and their ability to perform assessment and in identifying
the priority needs and health problems of patients with the DM type 2 and
eventually plan for appropriate nursing interventions to address the patients
individual needs.

Reason for choosing the case:

The global burden of diabetes is increasing worldwide as it is a costly disease

for developing economies of the world. The incidence of diabetes is growing around
the world. It is in the top ten leading causes of deaths. The International Diabetes
Federation (IDF) said in 2000 that there would be 320 Million diabetics globally by
2025. But it found out that in 2015, there were already 415 million diabetics aged
20-79. Filipinos are not an exemption to this incidence as more and more Filipinos
are affected by the disease. In the 2014 prevalence estimates published by the IDF,
it is estimated that there are 3.2 million cases of type 2 DM in the Philippines.
Alarmingly, our country is ranked in the top 15 in the world for diabetes.

Type II diabetes mellitus is a metabolic disease that can be prevented through

lifestyle modification, diet control, and control of overweight and obesity. Education
of the populace is still key to control of this emerging epidemic. Novel drugs are
being developed, yet no cure is available in sight for the disease, despite new
insight into the pathophysiology of the disease. Management should be tailored to
improve the quality of life of individuals with type II DM.

To reduce the acquisition and its effects on lives and our economy, it is
necessary to have an improved understanding of its etiology, pathogenesis, and
pathophysiology to focus therapeutic and research efforts appropriately. A
coordinated multidisciplinary approach is needed that involves us as health care
practitioners and other organizations to reduce the incidence of diabetes
significantly.

Since us nurses are on the front lines in interacting with patients and are
being called on to apply our knowledge, training and skills to help patients with
diabetes to achieve treatment goals, it is our duty to enhance our understanding
about the disease so that we can help our patients improve the quality of their daily
life as well as avoid potential complications later in life.
Background of the Disease:

Diabetes Mellitus is a chronic systemic disease characterized by elevated levels of

glucose in the blood (hyperglycemia) resulting from defects of insulin secretion,
insulin action or both.

TYPES OF DIABETES MELLITUS

1. Type 1 Diabetes
-previously referred to as insulin dependent diabetes mellitus (IDDM)
-other names: juvenile diabetes, brittle diabetes, ketosis prone diabetes
-characterized by destruction of pancreatic beta cells leading to absolute
insulin deficiency

2. Type 2 Diabetes
- Previously referred to as Non-insulin-dependent diabetes mellitus
-other names:adult or maturity onset diabetes,ketosis-resistant
diabetes,stable diabetes
-it is due to insulin resistance and impaired insulin secretion

3. Gestational Diabetes Mellitus

- Any degree of glucose intolerance with its onset during pregnancy.
Hyperglycemia develops during pregnancy because of the secretion of
placental hormones, which causes insulin resistance. In addition, circulating
cortisol and other metabolic changes lead to the breakdown of complex
carbohydrates to simple sugars.Often glucose levels become normal after
delivery.

4. Diabetes mellitus associated with other conditions or

syndromes
-diseases of the pancreas such as pancreatitis,trauma or pancreatectomy
-endocrinopathies such as acromegaly and Cushings syndrome
-excessive hormone production(cortisol,growth hormone,
cathecolamines,glucagon)
-drug/chemical induced(niacin, steroids such as prednisone and
dexamethasone)

DISTINGUISHING FEATURES OF TYPE 1 AND TYPE 2 DIABETES MELLITUS

FEATURE TYPE 1 TYPE 2
Age at onset Usually occurs before age 30, Usually occurs after age 30 but
but occurs at any age can also occur in children
Incidence -5-10% -90-95%
Type of onset Usually abrupt, with rapid Insidious, may be asymptomatic
onset of hyperglycemia or mildly asymptomatic; body
adapts to slow onset of
hyperglycemia
Endogenous Little or none Below normal, normal, or above
insulin production normal
Body weight at Ideal body weight or thin 85% of clients are obese; may
onset be of ideal body weight
ketosis Prone to ketosis, usually Resistant to ketosis, can occur
present at onset , often with infection or stress
present at onset, often
present during poor control
Manifestations Polyuria, polydipsia, Often none, may be mild
polyphagia, fatigue, weight manifestations of
loss hyperglycemia
Dietary and Essential essential
exercise
management
Exogenous insulin Dependent on insulin for 20%-30% of clients may require
administration survival insulin
Oral Not effective effective
hypoglycemic
agents

RISK FACTORS
Weight. About 80% of persons with DM type 2 are obese and the frequency of
diabetes in obese people is greater than in the general population. The interrelation
occurs because obesity is associated with insulin insensitivity in target issues(ie,
muscle, liver, and adipose cells)

Diet. Diet high in carbohydrates and fats.

Gender. Diabetes is more frequent in women than in men.

Alcohol. Excessive alcohol intake causes retention of maltose

Stress. Any form of stress with the neuroendocrine response increases

gluconeogenesis and glycogenolysis. Infection, life changes, various environmental
factors can be stressors that induce or worsen a diabetic state.

Fat distribution. If your body stores fat primarily in your abdomen, your risk of
type 2 diabetes is greater than if your body stores fat elsewhere, such as your hips
and thighs.

Inactivity. The less active you are, the greater your risk of type 2 diabetes. Physical
activity helps you control your weight, uses up glucose as energy and makes your
cells more sensitive to insulin.
Family history. The risk of type 2 diabetes increases if your parent or sibling has
type 2 diabetes.

Race. certain races including blacks, Hispanics, American Indians and Asian-
Americans are at high risk for developing type 2 diabetes

Age. The risk of type 2 diabetes increases as you get older, especially after age 30.
That's probably because people tend to exercise less, lose muscle mass and gain
weight as they age. But type 2 diabetes is also increasing dramatically among
children, adolescents and younger adults.

Prediabetes. Prediabetes is a condition in which your blood sugar level is higher

than normal, but not high enough to be classified as type 2 diabetes. Left untreated,
prediabetes often progresses to type 2 diabetes.

Gestational diabetes. If you developed gestational diabetes when you were

pregnant, your risk of developing type 2 diabetes later increases. If you gave birth
to a baby weighing more than 9 pounds (4.1 kilograms), you're also at risk of type 2
diabetes.

SIGNS AND SYMPTOMS

Increased thirst(polydypsia)and frequent urination(polyuria) As excess

sugar builds up in your bloodstream, fluid is pulled from the tissues. This may leave
you thirsty. As a result, you may drink and urinate more than usual.

Increased hunger(polyphagia). Without enough insulin to move sugar into your

cells, your muscles and organs become depleted of energy. This triggers intense
hunger.

Fatigue. If your cells are deprived of sugar, you may become tired and irritable.

Blurred vision. If your blood sugar is too high, fluid may be pulled from the lenses
of your eyes. This may affect your ability to focus clearly.

Slow-healing sores or frequent infections. Type 2 diabetes affects your ability

to heal and resist infections.

Dehydration. High amounts of glucose in the urine can cause increased urine
output and lead to dehydration. Dehydration causes increased thirst and water
consumption.

Numbness or tingling of the hands or feet. Due to excess sugar can injure the
walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in
the legs
DIAGNOSIS OF DIABETES MELLITUS

1. Fasting blood glucose (FBG) or Fasting blood sugar(FBS)

- A test to determine how much glucose (sugar) is in a blood sample client
has not ingested any nutrients other than water for at least 8 hours
-normal: 70-110 mg/dL
-impaired fasting glucose:110-126 mg/dL
-DM:>126 mg/dL for 2 readings

2. Casual blood glucose

- A blood glucose test measures the amount of a sugar called glucose in a
sample of your blood at any time of the day without regard to time since last
meal.
-DM:>200mg/dL

3. Postload/ postprandial blood glucose

- Postload blood glucose samples are drawn 2 hours after a standard meal
and reflect the efficiency of insulin mediated glucose uptake by peripheral
tissues. Normally, blood glucose should return to normal levels within 2
hours .
- The test should be performed , using a glucose load containing the
equivalent of 75 g anhydrous glucose dissolved in water
- Normal glucose tolerance:<140 mg/dL
- Impaired glucose tolerance: 140-200 mg/dL
- DM:>200 mg/dL

ADDITIONAL TEST TO EVALUATE DIABETES MELLITUS

4. Glycosylated hemoglobin(HbAIC)
-reflects serum glucose levels for the past 3-4 months. It is useful in
evaluating long term glycemic control.
Normal:6% -7%
DM:>7%
5. Oral Glucose Tolerance Test
-method which can help to diagnose instances of diabetes mellitus or insulin
resistance.
-The test is used to determine whether the body has difficulty metabolising
intake of sugar/carbohydrate. The patient is asked to take a glucose drink and
their blood glucose level is measured before and at intervals after the sugary
drink is taken.
People without diabetes
Fasting value (before test): under 6 mmol/L
At 2 hours: under 7.8 mmol/L
People with impaired glucose tolerance (IGT)
Fasting value (before test): 6.0 to 7.0 mmol/L
At 2 hours: 7.9 to 11.0 mmol/L
Diabetic levels
Fasting value (before test): over 7.0 mmol/L
At 2 hours: over 11.0 mmol/L
 6. C-Peptide Test
-C-peptide test is a blood test which is carried out to find out how much
insulin your body is producing . This may be useful for determining whether
you have type 1 or type 2 diabetes or whether you have insulin resistance.
-To measure level of c-peptide a fasting blood test is taken.
Stimulated C-Peptide test
-If the test is to diagnose either type 1 or type 2 diabetes, an injection
of glucagon may be given into the arm between two blood samples to
attempt to stimulate insulin production.
Normal: 0.51 to 2.72 (ng/mL)

7. Urinalysis
-(+) glycosuria
-(+)microalbuminuria-indicates that the blood vessels to your kidneys are
damaged.

COMPLICATIONS

Hyperglycemic hyperosmolar Nonketotic syndrome. HHNS is severe

hyperglycemia that occurs without ketosis and acidosis. Clinical manifestations
includes blood glucose level from 600-2000 mg/dL, hypotension, dehydration,
tachycardia, mental status changes, neurologic deficits and seizures.

Hypoglycemia. Occurs when blood glucose level falls to 60 mg/dL due to overdose
of insulin or oral hypoglycemic agents, omission of meals or too little food,
strenuous exercise or excessive activity and gastrointestinal upset. the client should
be instructed to always carry some form of fast acting simple carbohydrates.

Heart and blood vessel disease. Diabetes dramatically increases the risk of
various cardiovascular problems, including coronary artery disease with chest pain
(angina), heart attack, stroke, narrowing of arteries (atherosclerosis) and high blood
pressure. The risk of stroke is two to four times higher for people with diabetes, and
the death rate from heart disease is two to four times higher for people with
diabetes than for people without the disease, according to the American Heart
Association.

Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood
vessels (capillaries) that nourish your nerves, especially in the legs. This can cause
tingling, numbness, burning or pain that usually begins at the tips of the toes or
fingers and gradually spreads upward. Poorly controlled blood sugar can eventually
cause you to lose all sense of feeling in the affected limbs. Damage to the nerves
that control digestion can cause problems with nausea, vomiting, diarrhea or
constipation. For men, erectile dysfunction may be an issue.

Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel
clusters that filter waste from your blood. Diabetes can damage this delicate
filtering system. Severe damage can lead to kidney failure or irreversible end-stage
kidney disease, requiring dialysis or a kidney transplant.

Eye damage. Diabetes can damage the blood vessels of the retina (diabetic
retinopathy), potentially leading to blindness. Diabetes also increases the risk of
other serious vision conditions, such as cataracts and glaucoma.

Foot damage. Nerve damage in the feet or poor blood flow to the feet increases
the risk of various foot complications. Left untreated, cuts and blisters can become
serious infections. Severe damage might require toe, foot or even leg amputation.

MANAGEMENT

A. Diet
Low calorie diet, especially if the client is obese
The diet should consist of 20% protein, 30% fats and 50% carbohydrates
High fiber, especially vegetables. Fiber inhibits glucose absorption in the
intestines and prevents hyperglycemia. Fruit exchanges may be eaten,
according to the dietary exchange list. The diabetic client should not eat as
much fruit as he wants. Fruits contain fructose that is converted into glucose.
Therefore, eating too much fruits may cause hyperglycemia.
Complex Carbohydrates like rice, bread, pasta, root crops are preferred.
Simple carbohydrates like cakes, pastries are more likely to cause
hyperglycemia.
Sugar substitute sweeteners which are non caloric sweeteners such as
saccharin and aspartame are acceptable.

B. Activity and exercise

The benefits of regular pattern of exercise are as follows:
1. Exercise increases glucose uptake by the cells. Therefore, it lowers blood
glucose levels
2. Exercise lowers insulin requirements.
3. Exercise helps achieve desirable body weight.
4. Exercise helps maintain normal serum lipids. This reduces vascular risks.
Instruct client on dietary adjustments when exercising
Instruct client to monitor blood glucose before, during and after the exercise
period
Initially, the client who requires insulin should be instructed to eat 15 grams
carbohydrate snack before engaging in moderate exercise to prevent
hypoglycemia

C. Medications
Oral hypoglycemic agents
-stimulate islet of Langerhans to secrete insulin, increase sensitivity of
peripheral factors to insulin, decrease hepatic glucose output or delay
intestinal absorption of glucose, thus decreasing serum glucose levels
o Sulfonylureas- They work by increasing the amount of insulin your
body makes, and can lower blood sugar levels by approximately 20
 percent. Sulfonylureas are generally used if metformin does not
adequately control blood sugar levels when taken alone. It should not
be taken if you are allergic to sulfa drugs.
Dymelor(Acetohexamide)
Diabenese(Chlorpropamide)
Amaryl(Glimepiride)
Glucotrol(Glipizide)
Diabeta,Micronase(Glyburide)
Tolinase(Tolazamide)
Orinase(Tolbutamide)

o Non Sulfonylureas
Alpha Glucosidase Inhibitors- work by interfering with the
absorption of carbohydrates in the intestines. This helps to lower
blood sugar levels, but not as well as metformin or the
sulfonylureas. They can be combined with other medicines if the
first medicine does not lower blood sugar levels enough.
Precose(Acarbose)
Glyset(Miglitol)
Biguanide- improves how your body responds to insulin to reduce
high blood sugar levels. It is a pill that is usually started with the
evening meal; a second dose may be added one to two weeks later
(with breakfast). The dose may be increased every one to two
weeks thereafter.
Metformin(Glucophage)
Meglitinide-work to lower blood sugar levels, similar to the
sulfonylureas, and might be recommended in people who are
allergic to sulfa-based drugs. They are taken in pill form.
Meglitinides are not generally used as a first-line treatment because
they are more expensive than sulfonylureas and are short-acting, so
they must be taken with each meal
Starlix(Nateglinide)
Prandin(Repaglinide)
Thiozolidinediones- which work to lower blood sugar levels by
increasing the body's sensitivity to insulin. They are taken in pill
form and usually in combination with other medicines such as
metformin, a sulfonylurea, or insulin.
Actos(Pioglitazone)
Avndia(rosiglitazone)

Insulin
-indicated in type 2 DM when diet and weight control are ineffective to
maintain blood glucose levels.
-the peak of action time in insulin is important because f the possibility of
hypoglycemic reactions occurring at that time.

NURSING INTERVENTIONS FOR DIABETES MELLITUS

 Advice patient about the importance of an individualized meal plan in
meeting weekly weight loss goals and assist with compliance.
Assess patients for cognitive or sensory impairments, which may interfere
with the ability to accurately administer insulin.

Demonstrate and explain thoroughly the procedure for insulin self-injection.

Help patient to achieve mastery of technique by taking step by step
approach.

Review dosage and time of injections in relation to meals, activity, and

bedtime based on patients individualized insulin regimen.

Instruct patient in the importance of accuracy of insulin preparation and meal

timing to avoid hypoglycemia.

Explain the importance of exercise in maintaining or reducing weight.

Advise patient to assess blood glucose level before strenuous activity and to
eat carbohydrate snack before exercising to avoid hypoglycemia.

Assess feet and legs for skin temperature, sensation, soft tissues injuries,
corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes.

Maintain skin integrity by protecting feet from breakdown.

Advice patient who smokes to stop smoking or reduce if possible, to reduce

vasoconstriction and enhance peripheral flow.