-Tanta university

- Faculty of nursing

- Community health nursing department

- Semester 2nd year 4th

Prepared by:
Group: 12

1. Samar Ahmed Hassan Khafagy

2. Samar Ahmed Sayed Ahmed
3. Samar Reda Mohamed Shehab
4. Samar Mohamed abokasem

Under supervision of
Dr: DOAA ELKALA

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Vision and Mission of Faculty of Nursing:-
❖ Vision: -
Innovation and excellence on the local and regional
levels in the domains of
Education, learning, scientific research, community
service and the environmental
Development.
❖ Mission: -
The faculty of nursing, Tanta university aims at building
an effective academic
Environment that leads to graduating professional
nurses able to compete in the job
Market both locally and nationally and capable of
serving society and solving its
Health problems via nursing scientific research in the
light of values and traditions
Of the society
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Outlines

Introduction

Definition of diabetes mellitus

Pathophysiology of D.M
Types of D.M

Manifestation
Diagnosis
Complication
Prevention
• Primary prevention

• Secondary prevention

• Tertiary prevention

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 Introduction:

Diabetes is a major cause of morbidity and mortality. Diabetes mellitus refers to a

group of diseases that affect how the body uses blood sugar (glucose). Glucose is an
important source of energy for the cells that make up the muscles and tissues. It's
also the brain's main source of fuel.
The main cause of diabetes varies by type. But no matter what type of diabetes client
has, it can lead to excess sugar in the blood. Too much sugar in the blood can lead
to serious health problems.

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Defination of DM :
It is a disorder of carbohydrate metabolism characterized by impaired ability of the
body to produce or respond to insulin and maintain proper levels of glucose in the
blood.

Pathophysiology:
• Insulin is released into the blood by pancreas, in response to rising levels of blood
glucose after eating.
• The body cells absorbs glucose from the blood for use as fuel, for conversion to
other needed molecules.
• Glucagon acts in the opposite manner to insulin, it decreases glucose by
breakdown of glycogen to glucose.
• The body's cells that need glucose cannot efficiently absorb it if there is not
enough insulin available, cells do not respond well to insulin's effects (insulin
resistance), or the insulin itself is defective.
• Overall, this leads to high blood glucose levels that don't go down, inadequate
protein synthesis, and other metabolic abnormalities such metabolic acidosis in
cases of severe insulin shortage.
• When blood glucose levels are consistently high, the kidneys approach a
reabsorption threshold and the body excretes glucose in the urine (glycosuria). As
a result, there is a rise in the osmotic pressure of the urine, increased polyuria, and
greater fluid loss because the kidneys are unable to reabsorb water. Dehydration
and increased thirst result from the osmotically replaced lost blood volume, which
comes from water in body cells and other compartments (polydipsia). Moreover,
low intracellular glucose increases hunger, which causes overeating (polyphagia).

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 Types of DM

❖ Type 1 diabetes

❖ Type 2 diabetes

❖ Gestational diabetes
❖ Maturity onset diabetes of the young (MODY).
❖ Latent autoimmune diabetes in adults (LADA).

Type 1 Type 2
Insulin-dependent DM Non-Insulin-dependent DM
5% - 10% 90% - 95%
Onset Less 30 years Over 30 years
Weight Thin Obese
Genetic,
immunologic, or Obesity, heredity, or environmental
Etiology
environmental factors.
factors (e.g., virus).
Often have antibodies to
insulin even
before insulin treatment.
Insulin No islet ce0987ll antibodies
So, they have
little or no endogenous
insulin.
Most patients can control blood glucose
through weight loss if obese. Oral anti
diabetic agents may improve blood
Need insulin to
Treatment glucose levels if dietary modification
preserve life. and exercise are unsuccessful. May
need insulin on a short- or long-term
basis to prevent hyperglycemia.

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 Ketosis-prone when
Ketosis Ketosis rare
insulin absent.
Diabetic ketoacidosis Hyperosmolar Hyperglycemic State
Complication
(DKA) (HHS)`290-

➢ Gestational diabetes

Definition:

➢ It develops in 3% of pregnancy

➢ The insulin reserve in not sufficient in pregnancy

➢ Glucose level return to normal few weeks after labor

➢ 30-50 % develop DM after 10-15 years

Causes: hormones secreted by the placenta, which inhibit the action of insulin.
• Above-normal risk for perinatal complications, especially macrosomia

Risk factor

• Are overweight

• Are over age 35

• Had gestational diabetes during a past pregnancy

• Have given birth to a baby weighing more than 9 pounds

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 • Have a family history of type 2 diabetes

• Polycystic ovary syndrome. Having polycystic ovary syndrome — a

common condition characterized by irregular menstrual periods,
excess hair growth and obesity — increases the risk of diabetes.

MODY AND LADA

MODY.. (Maturity Onset LADA.. (Latent
Diabetes of the Young): Autoimmune Diabetes in
Adults): type 1.5
Cause: It results from a genetic defect It is considered a type of
in a single gene that affects type 1 diabetes, but it
insulin secretion, and is often develops slowly in adults.
passed down from one It occurs when the immune
generation to the next. It is system attacks the cells in
considered a rare genetic the pancreas that produce
disease. insulin.
Age: : It usually occurs in people It usually occurs in adults
before the age of 25. (over 30 years of age), but
with milder and more
gradual symptoms
compared to traditional
type 1 diabetes.
Symptom The symptoms of diabetes are Symptoms appear slowly
mild compared to other types, and may initially be
and may not require insulin thought to be type 2
treatment at first. diabetes.
Treatment It depends on oral medications It begins with drug

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 to regulate sugar levels, and the treatments but usually
patient often does not need progresses to the patient
insulin for a long time. needing insulin
Insulin: Patients are able to produce It causes a gradual
insulin, but in insufficient decrease in insulin
quantities. production, leading to the
need for insulin therapy a
few years after diagnosis.

Clinical manifestation of DM:

A- Clinical manifestations of all types of diabetes:

3ps
• Polyuria (increased urination).

• Polyphagia (increased appetite).

• Polydipsia.

B- Other symptoms:

• Fatigue and weakness.

• Sudden vision changes.

• Tingling or numbness in hands or feet.

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 • Dry skin.

• Skin lesions or wounds that slow to heal.

• Recurrent infections.

Diagnosis:

History

o Symptoms related to the diagnosis of diabetes:

✓ Symptoms of hyperglycemia
✓ Symptoms of hypoglycemia
✓ Frequency, timing, severity, and resolution
o Results of blood glucose monitoring
o Status, symptoms, and management of chronic complications
of diabetes

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 o Eye; kidney; nerve; genitourinary and sexual, bladder, and
gastrointestinal; cardiac; peripheral vascular; foot complications
associated with diabetes
o Compliance with prescribed dietary management plan
o Adherence to prescribed exercise regimen
o Compliance with prescribed pharmacologic treatment (insulin or
oral antidiabetic agents)
o Use of tobacco, alcohol, and prescribed and over-the-counter
medications/drugs
o Lifestyle, cultural, psychosocial, and economic factors that may
affect diabetes treatment.

Physical Examination

o Blood pressure (sitting and standing to detect orthostatic changes)

o Body mass index (height and weight)
o Fundoscopic examination
o Foot examination (lesions, signs of infection, pulses)
o Skin examination (lesions and insulin-injection sites)
o Neurological examination
o Vibratory and sensory examination using monofilament
o Deep tendon reflexes
o Oral examination
o Ophthalmology
o Podiatry
o Dietitian
o Diabetes educator
Lab investigation
1. Signs and symptoms
2. Fasting blood glucose level greater or equal to 126 mg\dl or 7 mmol\L
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3. 2-hours post-prandial greater or equal to 200 mg\dl or 11,1 mmol\L
4. Random blood glucose level equal or greater than to 200 mg\dl
➢ Glycated hemoglobin (A1C) test: This blood test, which doesn't
requirefasting, indicates your average blood sugar level for the past
two to three months. It measures the percentage of blood sugar
attached to hemoglobin, the oxygen-carrying protein in red blood cells.
The higher your blood sugar levels, the more hemoglobin you'll have
with sugar attached.
- An A1C level of 6.5% or higher on two separate tests indicates that there
is diabetes.
- An A1C between 5.7 and 6.4 % indicates prediabetes.
- Below 5.7 is considered normal.

➢ Random blood sugar test: A blood sample will be taken at a

random time. Regardless of when you last ate, a blood sugar level of
200 milligrams per deciliter (mg/dL) — 11.1 millimoles per liter
(mmol/L)
— or higher suggests diabetes.

➢ Fasting blood sugar test: A blood sample will be taken after an

overnight fast. A fasting blood sugar level less than 100 mg/dL
(5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125
mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL
(7mmol/L) or higher on two separate tests, you have diabetes.

➢ Oral glucose tolerance test: For this test, you fast overnight,
and the fasting blood sugar level is measured. Then you drink a

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 sugary liquid,and blood sugar levels are tested periodically for the
next two hours.
A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A
reading of more than 200 mg/dL (11.1 mmol/L) after two hours indicates
diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0
mmol/L) indicates prediabetes.

Urine test: If type 1 diabetes is suspected, your urine will be tested to look for the
presence of a byproduct produced when muscle and fat tissue are used for energy
because the body doesn't have enough insulin to use the available glucose (ketones).
Your doctor will also likely run a test to see if you have thedestructive immune
system cells associated with type 1 diabetes called autoantibodies.

Five component of diabetes management:

1) Exercise. 2) Diet. 3) Medication.

4) Monitoring glucose levels and ketones. 5) Patient education.

Exercise:
1. Patient with keton urine not exercise until the keton body become negative in test.
2. The patient should test blood glucose & take a dose of insulin if needed before
engage of exercise and eat any snack such as fruits.
3. Use appropriate foot wear.
4. Avoid exercises in…
• Extreme cold or hot
• Poor metabolic control.

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5. Gradually increase of length of exercise

Diet :

1. Meal planning:
To control of calories intake from carbohydrate rice cereal, bread, sugar.
2. Carbohydrate:
It has a greater effect on blood glucose level so decrease amount of calories
from bread & cereal and distribute it to fat and protein such as meat, fish.
3. Fats:
Reduced to less than 30%, to prevent the development of coronary artery
disease
4. Minerals:
Iron improves hemoglobin and blood so improve metabolism and glycogeness
in liver.
5. Vitamins:
Diabetic patient must increase vitamins intake.

Medication:
Types of hypoglycemic drugs:
1- Injection (insulin). 2- Oral hypoglycemic agent.
1) Insulin
Indications of insuline:
✓ In Type 1 DM: it is the only therapy.
✓ In Type 2 DM: insulin is indicated for refractory hyperglycemia.
✓ Complicated cases as DKA.

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✓ During pregnancy.
✓ When exposure to stress from surgery or infection.

Types of insulin according to its source:

A. Conventional derived from beefs and less pure.
B. Human insulin produced by genetic engineering, less allergic and pure
Rapid- Short- Intermediate- Mixed Long-
Type acting acting acting Insulin insulin acting
insulin insulin insulin
Onset of 5 to 15 30 min. 1 to 2 hrs. 15 to 30 90 min.
action min. min.
Peak of action 30 to 60 1 to 3 hrs. 4 to 8 hrs. 2 to 6 hrs. Peak
min. less.
Time of Injected Injected Between Commonly Once a
administration at the 15 to 30 meals. twice a day day at
start of minutes before any time.
the meal. before meals.
meals.
Duration of 2 to 5 hrs. 4 to 8 hrs. 8 to 12 hrs. 10 to 16 Up to 24
action hrs. hrs.

2) Oral hypoglycemic agent

Indicated for type 2 DM with stable and less complicated conditions

❖ Metformin (Fortamet, Glumetza, others) is generally the first medicine
prescribed for type 2 diabetes. It works mainly by lowering glucose production
in the liver and improving the body's sensitivity to insulin, so it uses insulin
more effectively.
Some people experience B-12 deficiency and may need to take supplements. Other
possible side effects, which may improve over time, include:
• Nausea.

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 • Abdominal pain.
• Bloating.
• Diarrhea.

Complications of DM:

Acute Complications of Diabetes

There are three major acute complications of diabetes related to

short-term imbalances in blood glucose levels:
• Hypoglycemia
• HHNS, which is also called hyperglycemic hyperosmolar nonketotic
coma or hyperglycemic hyperosmolar syndrome.

• DKA

Hypoglycemia Hyperglycemia
Definition Deficiency of glucose in the blood Excess of glucose in the blood
stream. stream.
Blood Blood glucose level drops less than Blood sugar level rise more
glucose level 70mg/dl than 130mg|dl(FBG)
Above 200(RBG)
Causes ➢ Drugs: insulin. ➢ Insufficient insulin, due to
➢ Insulinoma: tumor of pancreatic ẞ missed doses, or too low a
cell that secrete excessive amounts dose for what is needed at
of insulin that causes the time, or not enough of
hypoglycemia. your other diabetes

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 ➢ Starvation and fasting. medications
➢ Hepatic dysfunction. ➢ Not enough physical activity
➢ Large insulin dose (physical activity
➢ Missed meal. encourages the body to use
glucose and makes the body
more sensitive to insulin)

➢ Too much food,

particularly food
containing high levels of
carbohydrates
onset Usually rapid with good health Usually slow with ill health a
previously few days before
Signs and ➢ Looking pale ➢ Dry mouth
symptoms ➢ Shakiness ➢ Increased thirst
➢ Sweating ➢ Frequent urination
➢ Headache ➢ Headache
➢ Hunger or nausea ➢ Blurry vision
➢ An irregular or fast heartbeat ➢ Nausea
➢ Fatigue ➢ Feeling week or tired
➢ Irritability or anxiety ➢ Shortness of breath
➢ Difficulty concentrating ➢ Fruity smelling breath
➢ lightheadedness
➢ As hypoglycemia worsens,
signs and symptoms can
include:
➢ Confusion, unusual behavior or

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 both, such as the inability to
complete routine tasks
➢ Loss of coordination
➢ Slurred speech
➢ Blurry vision.
➢ Severe hypoglycemia may
cause:
➢ Unresponsiveness (loss of
consciousness)
➢ Seizures
managment ➢ Monitor the patient’s blood glucose ➢ may require emergency
level. treatment in the form of
➢ Assess the patient’s mental status. fluid and electrolyte
➢ The nurse can administer D50 IV replacement and/or insulin
to quickly treat hypoglycemia therapy. Long-term, your
when the patient is not alert or health care professional
oriented. Glucagon may be given may recommend a
IM and the family can be educated combination of the
on its administration. If the patient following:
is capable of swallowing safely,
juice, milk, or glucose gel can be ➢ Regular exercise as a way
given. to control blood sugar.
➢ Medication as prescribed
➢ Provide safety. Hypoglycemia by a health care
can cause seizures or professional.
inappropriate behavior. It is the ➢ A healthy diet that reduces
nurse’s responsibility to keep the the amount of sugary foods

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 patient safe in the event of a and drinks and encourages
seizure and prevent the risk of the consumption of whole
injury through fall precautions. foods.
➢ Recheck blood sugar levels 15 ➢ Regular blood sugar
minutes after treatment monitoring to ensure you’re
in the optimal range.

Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis is typically characterized by hyperglycemia of

over 250 mg/dL, a bicarbonate level of less than 18 mEq/L, and a of pH
less than 7.30, with ketonemia and ketonuria.
It is a critical illness that manifests with severe hyperglycemia, metabolic
acidosis, and fluid and electrolyte imbalances elevation of counter-
regulatory hormones such as growth hormone, cortisol, and glucagons.

Degree of DKA:
- Mild DKA can be categorized by a pH level of 7.25-7.3 and a serum
bicarbonate level between 15-18 mEq/L
-Moderate DKA can be categorized by a pH between 7.0-7.24 and a

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serum bicarbonate level of 10 to less than 15 mEq/L.

-Severe DKA has a pH less than 7.0 and bicarbonate less than 10 mEq/L.

Signs and symptoms of DKA

1. Kussmaul’s respirations

2. The expired air has a fruity odor caused by the ketones

3. Polyuria, the body becomes dehydrated very quickly

4. Tachycardia, hypotension, and shock can result.

5. High blood glucose also causes potassium to leave the cells and
accumulate in the blood (hyperkalemia).
6. The patient loses consciousness and death occurs if DKA is not treated

Treatment of DKA

1. IV fluids, IV insulin, and blood glucose monitoring

• Assist with monitoring blood glucose levels closely and notify the
RN or physician when the desired level is reached.
2. Glucose should be added to the IV when the blood glucose drops to
250 mg/dL to avoid hypoglycemia.
3. Potassium should also be monitored, because the serum potassium
level drops rapidly as it reenters the cells.
4. The cause of the DKA should be identified and treated

Long-Term Complications of Diabetes

These are long-term problems that can develop gradually, and can lead to

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serious damage if they go unchecked and untreated.
• Eye problems (retinopathy):- Some people with diabetes develop an
eye disease called diabetic retinopathy which can affect their eyesight. If
retinopathy is picked up – usually from an eye screening test - it can be
treated and sight loss prevented.
• Foot problems: Having diabetes means that you’re more at risk of
serious foot problems and which can lead to amputation if untreated.
Nerve damage can affect the feeling in your feet and raised blood sugar
can damage the circulation, making it slower for sores and cuts to heal.
That’s why it’s important to tell your GP if you notice any change in
how your feet look or feel.
• Cardiovascular disease: When you have diabetes, high blood sugar for
a period of time can damage your blood vessels. This can sometimes
lead to heart attacks and strokes.
• Kidney problems (nephropathy): Diabetes can cause damage to your
kidneys over a long period of time making it harder to clear extra fluid
and waste from your body. This is caused by high blood sugar levels and
high blood pressure. It is known as diabetic nephropathy or kidney
disease.
• Nerve damage (neuropathy): Some people with diabetes may develop
nerve damage caused over time by high blood sugar levels. This can
make it harder for the nerves to carry messages between the brain and
every part of our body so it can affect how we see, hear, feel and move.
• Gum disease and other mouth problems: Too much sugar in your
blood can lead to more sugar in your saliva. This brings bacteria which
produces acid which attacks your tooth enamel and damages your gums.
The blood vessels in your gums can also become damaged, making
gums more likely to get infected.
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 • Skin conditions: Diabetes may leave you more susceptible to skinproblems,
including bacterial and fungal infections.

Gestational diabetes complication

➢ For mother
✓ polyhydramnios
✓ pre-eclampsia
✓ prolonged labor
✓ uterine atony
✓ post-partum Hemorrhage
✓ infection
➢ For baby

✓ Prematurity
✓ Perinatal asphyxia
✓ Respiratory distress syndrome
✓ Hypoglycemia
✓ Macrosomia (obesity)
✓ Cardiomyopathy

Prevention:-

Type 1 diabetes isn’t preventable because it’s caused by a problem with the
immune system. Some causes of type 2 diabetes, such as your genes or age,
aren’t under your control either.
1. Primary prevention:

Actions taken prior disease onset which removes the probability that a

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disease will ever occur i.e. Prepathogenic phase of disease/health problem.
Thus prevent the onset of specific diseases via risk reduction
Aim: limiting incidence of the disease by controlling causes & risk factors

e.g. cholesterol & coronary heart disease, health education, Immunization

General prevention

▪ Health promotion

▪ Heath education

▪ Environmental sanitation.

Specific prevention

First: general prevention

➢ Health promotion

▪ Environmental modification.

▪ Nutritional intervention.

▪ Life style and behavioral changes.

▪ Personal hygiene

▪ Health education
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 ▪ Socio-economic development

▪ Genetic counseling.

➢ Health education

_ Control life style and behavioral changes

_ Good nutrition and healthy diet

_ Exercise performance

_ Doing hygiene

_ Sleep rest

_Avoiding smoking and alcohol

➢ Environmental sanitation:

Generally it includes:

1) Air pollution control: such as proper ventilation & proper control of air
pollutants.
2) Water Sanitation & provision of safe water supply.
3) Proper waste disposal (refuge & sewage): both solid and liquid waste
disposal.
4) Control of food handlers and food sanitation

Second: specific prevention

➢ Specific health education

o Lose extra weight. Losing weight reduces the risk of diabetes.

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 o Lose weight Lower your blood sugar Boost your sensitivity to insulin —
which helps keep your blood sugar within a normal range..
o Exercise:-

✓ Exercising for 30 minutes per day (Walking-Cycling-Swimming-

a Team sports-Aerobic-dance-Weightlifting-Resistance band
exercises).
✓ Achieving a healthy BMI gradually.

✓ Take water before, during, after exercise.

✓ You should start with warming up.

✓ You should end with cooling down.

✓ You should give the insulin.

✓ You should measure the vital sings.

o Diet:-

✓ Replace foods that contain simple starches, such as rice, white

bread and sweets, with foods that contain fiber, such as whole
wheat grains, vegetables and other foods rich in dietary fiber.
✓ Reducing the amount of saturated fat in the diet.
✓ Drinking water helps control blood sugar.

✓ Taking balanced diet.

✓ Daily food care.

✓ Eat healthy fats Fatty foods are high in calories and should be
eaten in moderation
2. Secondary prevention:

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Aims: early detection, cure of patients & reduce risk of complications with
finally decrease disease prevalence.
• Case finding •
Control of case
• Control of contact

Screening for sub-clinical disease (early detection) e.g. breast cancer

screening. Either in screening surveys or in periodic medical examinations.
1) Case finding (individual and community) & treatment. Requirements: Safe &
accurate method of detection (better preclinical) plus effective prevention
method.
2) Treatment: It includes symptomatic treatment of general constitutional
manifestations and specific treatment by use of drugs (e.g. hypoglycemic
drugs).

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 • foot care habits .
Inspect your feet Check your feet and toes, inspecting the tops, sides,
soles, heels, and the area in between the toes. If you’re physically unable to
inspect your own feet, use a mirror or ask someone to help Contact your doctor
immediately if you discover any sores, redness, cuts, blisters, or bruises.

Wash your feet wash your feet every day in warm water with mild soap.
Hot water and harsh soaps can damage your skin. Check the water temperature
with your fingers or elbow before putting your feet in. Your diabetes may make
it difficult to sense water temperature with your feet.

Dry your feet Pat your feet to dry them and make sure to dry well.
Infections tend to develop in moist areas, so make sure you dry the area
between your toes well.

Moisturize dry skin If the skin on your feet feels rough or dry, use lotionor
oil. Do not use lotion between your toes.

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 3. Tertiary prevention:

Aim:
Rehabilitation and prevent further deterioration or reduce complications
Rehabilitation:
1- Physical rehabilitation:
Restoration of function or physical loss.
Training patient for suitable work.
Encourage patient as medication prescribed.
Maintain on follow up& comply with health habits.
To be productive.
2- Social rehabilitation:
Restoration of family and social relationships.
Assess patient economic level, housing conditions& provide financial aids.
Replacement unsanitary slums with sanitary housing.
3- Psychological rehabilitation:
Restoration of personal confidence.
Encourage patient to express emotions& promote self-esteem.
Emotional support, allow to accept existing complication

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