1. Diabetes: heterogeneous group of diseases involving the disruption of the metabolism of carbohydrates, fats, and protein. If uncontrolled, serious vascular and neurological changes occur.

    1. Types:
      1. Type 1: formerly called insulin-dependent diabetes rnellitus (IDDM); and also formerly called “juvenile-onset diabetes.” Insulin needed to prevent ketosis; onset usually in youth but may occur in adulthood; prone to ketosis, unstable diabetes.
      2. Type 2: formerly called non-insulin-dependent diabetes rnellitus (NIDDM); and also formerly called “maturity-onset diabetes” or “adultonset diabetes.” May be controlled with diet and oral hypoglycémies or insulin; patient less apt to have ketosis, except in presence of infection. May be further classified as obese type 2 or nonobese type 2.
      3. Type 3: gestational diabetes rnellitus (GDM): glucose intolerance during pregnancy in women who were not known to have diabetes before pregnancy; will be reclassified after birth; may need to be treated or may return to prepregnancy state and need no treatment.
      4. Type 4: diabetes secondary to another condition, such as pancreatic disease, other hormonal imbalances, or drug therapy such as receiving glucocorticoids.
    2. Pathophysiology:
      1. Type 1-absolute deficiency of insulin due to destruction of pancreatic beta cells by the interaction of genetic, immunological, hereditary, or environmental factors.
      2. Type 2-relative deficiency of insulin due to:
        1. An islet cell defect resulting in a slowed or delayed response in the release of insulin to a glucose load; or
        2. Reduction in the number of insulin receptors from continuously elevated insulin levels; or
        3. A postreceptor defect; or
        4. A major peripheral resistance to insulin induced by hyperglycemia. These factors lead to deprivation of insulin-dependent cells-a marked decrease in the cellular rate of glucose uptake, and therefore elevated blood glucose.
    3. Risk factors:
      1. Obesity.
      2. Family history of diabetes.
      3. Age 45 or older.
      4. Women whose babies at birth weighed more than 9 lb.
      5. History of autoimmune disease.
      6. Members of high-risk ethnic group (AfricanAmerican, Latino, or Native American).
      7. History of gestational diabetes rnellitus.
      8. Hypertension.
      9. Elevated HDL.
    4. Assessment:
      1. Subjective data:
        1. Eyes: blurry vision.
        2. Skin: pruritus vulvae.
        3. Neuromuscular: paresthesia, peripheral neuropathy, lethargy, weakness, fatigue, increased irritability.
        4. GI: polydipsia (increased thirst).
        5. Reproductive: impotence.
      2. Objective data:
        1. Genitourinary: polyuria, glycosuria, nocturia (nocturnal enuresis in children).
        2. Vital signs:
          1. Pulse and temperature normal or elevated.
          2. BP normal or decreased, unless complications present.
          3. Respirations, increased rate and depth (Kussmaul's respirations).
        3. GI:
          1. Polyphagia, dehydration.
          2. Weight loss, failure to gain weight.
          3. Acetone breath.
        4. Skin: cuts heal slowly; frequent infections, foot ulcers, vaginitis.
        5. Neuromuscular: loss of strength, peripheral neuropathy.
        6. Lab data:
          1. Elevated:
            1. Blood sugar >126 mg/dL fasting or 200 mg/dL 1-2 hours after eating.
            2. Glucose tolerance test.
            3. Glycosuria (>170 mg/100 mL).
            4. Potassium (>5) and chloride (>145).
            5. Hemoglobin A1c >7%.
              1. pH (<7.4).
              2. PaCO2 (<32).
          2. Decreased:
        7. Long-term pathological considerations:
          1. Cataract formation and retinopathy: thickened capillary basement membrane, changes in vascularization and hemorrhage, due to chronic hyperglycemia.
          2. Nephropathy: due to glomerulosclerosis, arteriosclerosis of renal artery and pyelonephritis, progressive uremia.
          3. Neuropathy: due to reduced tissue perfusion; affecting motor, sensory, voluntary, and autonomic functions.
          4. Arteriosclerosis: due to lesions of the intimal wall.
          5. Cardiac: angina, coronary insufficiency, myocardial infarction.
          6. Vascular changes: occlusions, intermittent claudication, loss of peripheral pulses, arteriosclerosis.
    5. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to inability to metabolize nutrients and weight loss.
      2. Altered nutrition, more than body requirements, related to excessive glucose intake.
      3. Risk for injury related to complications of uncontrolled diabetes.
      4. Body image disturbance related to long-term illness.
      5. Knowledge deficit related to management of long-term illness and potential complications.
      6. Ineffective individual coping related to inability to follow diet/medication regimen.
      7. Sexual dysfunction related to impotence from diabetes and treatment.
    6. Nursing care plan/implementation:
      1. Goal: obtain and maintain normal sugar balance.
        1. Monitor: vital signs; blood glucose before meals, at bedtime, and as symptoms demand (urine testing for glucose levels is not as accurate as capillary blood testing).
        2. Medications:
          1. Oral hypoglycemics:
            1. Sulfonylureas; tolbutamide (Orinase), chlorpropamide (Diabenese), tolazamide (Tolinase), acetohexamide (Dymelor), glimepiride (Amaryl), glyburide (DiaBeta and Micronase), and glipizide (Glucocotrol).
            2. Others: metformin (Glucophage) increases body’s sensitivity to insulin. Acarbose (Precose) inhibits cells of the small intestine from absorbing complex carbohydrates.
          2. Insulin (available as pork, beef, or human synthetic insulin):
            1. Lispro, a rapid-acting analogue of human insulin.
            2. Short acting (crystalline, regular) (Humulin R).
            3. Intermediate acting (Lente and NPH).
            4. Slow acting (protamine zinc).
            5. Long, extended acting (Ultralente, Ultratard).
          3. Methods of administration:
            1. Subcutaneous injection.
            2. Prefilled injectable insulin pens (Novopen and Novolin).
            3. Continuous subcutaneous insulin infusion therapy (insulin pumps).
        3. Diet, as ordered.
          1. Carbohydrate, 50-60%; protein, 20%; fats, 30% (saturated fats limited to 10%, unsaturated fats, 90%).
          2. Calorie reduction in obese adults; enough calories to promote normal growth and development for children or nonobese adults.
          3. Limit refined sugars.
          4. Add vitamins, minerals as needed for well-balanced diet.
        4. Monitor for signs of acute (hypoglycemia, ketoacidosis) or chronic (circulatory compromise, neuropathy, nephropathy, retinopathy) complications.
      2. Goal: health teaching:
        1. Diet: foods allowed, restricted, substitutions.
        2. Medications: administration techniques, importance of using room-temperature insulin and rotating injection sites to prevent tissue damage.
        3. Desired and side effects of prescribed insulin type; onset, peak, and duration of action of prescribed insulin.
        4. Blood glucose testing techniques.
        5. Signs of complications.
        6. Importance of health maintenance:
          1. Infection prevention, especially foot and nail care.
          2. Routine checkups.
          3. Maintain stable balance of glucose by carefully monitoring glucose level and making necessary adjustments in diet and activity level; seeking medical attention when unable to maintain balance; regular exercise program.
    7. Evaluation/outcome criteria:
      1. Optimal blood-glucose levels achieved.
      2. Ideal weight maintained.
      3. Adequate hydration.
      4. Carries out self-care activities: blood or urine testing, foot care, exchange diets, medication administration, exercise.
      5. Recognizes and treats hyperglycemic or hypoglycemic reactions.
      6. Seeks medical assistance appropriately.