NRSG265 exam
Diabetes mellitus (DM) A disease in which the body's ability to produce or respond to the hormone insulin is
impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of
glucose in the blood
DM type 1 insulin is functionally absent due to destruction of beta cells of pancreas; where
insulin would normally be produced. starts in children ages 4 or older, adolescense.
symptoms include polyuria, polydipsia, polyphagia, nausea, weight loss, fatigue,
blurred vision, and dehydration
Causes of Type 1 DM · Autoimmune destruction of the beta cells
· Genetic susceptibility
· Environmental factors - drugs, viruses à triggers cell-mediated destruction of the
beta cells of the pancreas
· Idiopathic - beta cell destruction in the absence of autoimmune response
· Non-immune mediated diabetes - secondary to their conditions - pancreatitis
Initial signs and symptoms of type 1 DM · 3 Ps - polyphagia (increased appetite), Polyuria (increased urine output) and
polydipsia (increased thirst)
· Fatigue
· Weight loss
· Blurred vision
· Confusion
Later signs and symptoms of type 1 DM · Nausea and vomiting
· Abdominal pain
· Tachycardia
· Tachypnoea
· Ketonic breath
· Metabolic acidosis
· Seizures
· Coma
Pathophysiology of type 1 DM The body's immune system mistakenly attacks and destroys the insulin-producing
cells in the pancreas. This results in a lack of insulin, a hormone that helps regulate
blood sugar levels. Without sufficient insulin, glucose cannot enter the cells for
energy, leading to high blood sugar levels. People with this require insulin injections
or the use of an insulin pump to manage their blood sugar levels.
Mangement Type 1 DM Insulin is currently the only treatment option available
Types of insulin In Australia, insulin comes in 5 main types:
1. rapid-acting or ultra-short acting
2. short-acting
3. intermediate-acting
4. long-acting
5. pre-mixed insulin
Rapid acting insulin Given 10-15 minutes prior to eating a meal
Must eat immediately after administration
Used to reduce BGL post a meal - acts most like endogenous insulin
Administered in conjunction with an intermediate or long acting insulin
Clear in appearance
The endocrine system Glands secrete hormones that regulate processes such as growth, reproduction,
and nutrient use (metabolism) by body cells.
Short-acting insulin Given 30 minutes prior to eating a meal
Used to reduce BGL post a meal
Administered in conjunction with an intermediate or long acting insulin
Clear in appearance
, NRSG265 exam
Intermediate acting insulin These are considered basal (background insulins)
Maintains glycaemic control once the rapid- or short-acting insulins are depleted
Does not need to be given with food
Cloudy in appearance - mix well prior to use
Long-acting insulin Slow and steady release of insulin
Administered once or twice daily
Does not need to be given with food
Clear in appearance
Mixed insulin Combination of rapid- or short-acting and intermediate-acting insulin
The insulin has an onset of the rapid- or short-acting insulin, and will last the
duration of the intermediate-acting insulin
type 2 diabetes mellitus diabetes in which either the body produces insufficient insulin or insulin resistance
(a defective use of the insulin that is produced) occurs; the patient usually is not
dependent on insulin for survival
Insulin for T2 DM Take this due to
· Acute illness or stress leading to an increased need for insulin (surgery,
pregnancy, physical stress, emotional stress);
· Oral hypoglycaemic agents become less effective in maintaining normal BGL over
time;
· Over time, in this the pancreas becomes unable to produce sufficient insulin due to
the increasing insulin resistance. This will require insulin to maintain glycaemic
control;
· Non-adherence to diet and exercise can lead to persistent hyperglycemia that only
insulin can control.
T2 DM risk factors · Genetic factors and family history
· Overweight and obese
· Sedentary lifestyle
· Age >35 and overweight
· ATSI, Indian subcontinent, pacific islander or Chinese background
· History of gestational diabetes
· Many modifiable risk factors
T2 DM pathophysiology Characterised by insulin resistance due to the following:
- Increased insulin resistance at the cell
- Reduction in the number of insulin binding sites
- Decrease in the amount of insulin binding to the receptors
- Decrease beta cell responsiveness to increased glucose levels
Initial signs and symptoms of T2DM · 3 Ps - polyphagia (increased appetite), Polyuria (increased urine output) and
polydipsia (increased thirst)
· Fatigue
· Hyperglycaemia
Late signs and symptoms of T2DM · Repeated infections
· Poor wound healing
· Blurred vision
· Weight changes
Mangement for T2DM 1. first line management
2. oral hypoglycaemic agents
3. holistic approach
Treatment for T2DM 1. Diet
2. Exercise
3. Close monitoring of BGL
a. Target 6-6mmol/L fasting
4. Oral hypoglycaemic agents (OHA) or insulin
5. Prevention of short- and long-term complications of DM
, NRSG265 exam
Hypoglycaemia Defined as a BGL < 4mmol/L Can be FATAL (low blood sugar levels)
Causes of hypoglycaemia · Medication overdose (OHA or insulin)
· Not eating enough carbohydrates or skipping meals
· Excess alcohol consumption
· Excessive exercise
· Malnutrition
Early signs and symptoms of hypoglycaemia · BGL < 4 mmol/L
· Trembling
· Sweating
· Pale
· Skin - cool, pale & clammy
· Hunger
· Headache
· Dizziness
Later signs and symptoms of hypoglycaemia · Difficulty concentrating
· Vision changes
· Anxiety
· Seizures
· Altered conscious state/unconsciousness
· Coma
· Death
Management of mild hypoglycemia 1. Check BGL < 4 mmol/L
2. Eat 15-20 grams of fast acting carbohydrates
3. Recheck BGL >4 mmol/L
4. Followed by 20 grams of slow acting carbohydrates
Management of severe hypoglycemia · If the person is unconscious, drowsy or not able to swallow, do not give them
anything to eat or drink
· Medical emergency!
1. Call for help
2. Position patient on their side, ensuring airway is clear – WHY?
3. IV dextrose bolus
4. If no IV access, administer IM glucagon (can cause vomiting) then IV dextrose as
soon as possible
5. Once patient is stabilised and able to eat and drink, follow up with 20 grams of
slow acting carbohydrates
Hyperglycaemia high blood glucose concentration
Complications of type 1 DM 1. Diabetic ketoacidosis (DKA)
2. higher rate of other autoimmune disease
Diabetic Ketoacidosis · Very serious medical condition related to hyperglycaemia, which gradually
develops over hours - days
· Due to lack of insulin leading to glucose build up in the blood
Risk factors:
1. New diagnosis
2. Acute stress or illness
3. Omission of insulin
4. Lack of access to medical care
DKA clinical manifestations Laboratory markers:
· BGL >11mmol/L
· Ketones present in blood and urine
· pH <7.3, HCO3- <15mmol/L
· K+ and Na+ changes
· High serum osmolarity
, NRSG265 exam
DKA - management 1. Correction of dehydration:
· Fluid resuscitation → cerebral oedema risk
· IVF - 24-72 hours
2. Reverse ketosis:
· Insulin infusion
· Dextrose infusion with/without KCl
3. Acid-base and electrolyte corrections:
· Regular 1/24 BGLs and 1-4/24 ABGs
· Urine ketones
· Close monitoring of U&Es (Na+ and K+ )
· Nurse pt 30°
· NBM
· Strict bed rest
· Strict FBC
· Cardiac monitoring
· Treat underlying cause
· Reintroduction of fluids and SC insulin once DKA resolved and significant clinical
improvement
Complications of Type 2 DM Hyperosmolar hyperglycaemic state (HHS)
Hyperosmolar hyperglycaemic state (HHS) Complication arising from Type 2 diabetes, often seen at initial presentation
Develops over days to weeks → dehydration and metabolic disturbances are more
severe
Characteristics of HHS · Severe hyperglycaemia
· Severe dehydration, hypovolaemia
· High serum osmality
· Very unwell
· No significant ketoacidosis
· Less common than DKA, but higher mortality rate 5-10%
Risk factors/causes of HHS · Elderly - reduced thirst or fluid intake
· Non-compliance or missed doses
· Poorly controlled Type 2 diabetes
· Infection and illness (MI, stroke, sepsis)- hyperglycaemia
· Drugs that reduce insulin action (glucocorticoids)
HHS lab markers · BGL > 30mmol/L
· Ketones can be present/absent
· pH > 7.3, HCO3- >15mmol/L
· K+ and Na+ changes
· High serum osmolality
Earlier signs and symptoms of HHS · Polyuria +
· Polydipsia +
Later signs and symptoms of HHS · Sunken eyes
· Tachycardia
· Hypotension
· Dry skin
· Headache
· Weakness
· Cramps
· Fatigue and lethargy
· Abdominal pain, N+V
· Seizures
· Altered LOC
· Coma
HHS - management IVF, Insulin infusions, regular BGLS, urine ketones, NBM, strict FBC.
Diabetes mellitus (DM) A disease in which the body's ability to produce or respond to the hormone insulin is
impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of
glucose in the blood
DM type 1 insulin is functionally absent due to destruction of beta cells of pancreas; where
insulin would normally be produced. starts in children ages 4 or older, adolescense.
symptoms include polyuria, polydipsia, polyphagia, nausea, weight loss, fatigue,
blurred vision, and dehydration
Causes of Type 1 DM · Autoimmune destruction of the beta cells
· Genetic susceptibility
· Environmental factors - drugs, viruses à triggers cell-mediated destruction of the
beta cells of the pancreas
· Idiopathic - beta cell destruction in the absence of autoimmune response
· Non-immune mediated diabetes - secondary to their conditions - pancreatitis
Initial signs and symptoms of type 1 DM · 3 Ps - polyphagia (increased appetite), Polyuria (increased urine output) and
polydipsia (increased thirst)
· Fatigue
· Weight loss
· Blurred vision
· Confusion
Later signs and symptoms of type 1 DM · Nausea and vomiting
· Abdominal pain
· Tachycardia
· Tachypnoea
· Ketonic breath
· Metabolic acidosis
· Seizures
· Coma
Pathophysiology of type 1 DM The body's immune system mistakenly attacks and destroys the insulin-producing
cells in the pancreas. This results in a lack of insulin, a hormone that helps regulate
blood sugar levels. Without sufficient insulin, glucose cannot enter the cells for
energy, leading to high blood sugar levels. People with this require insulin injections
or the use of an insulin pump to manage their blood sugar levels.
Mangement Type 1 DM Insulin is currently the only treatment option available
Types of insulin In Australia, insulin comes in 5 main types:
1. rapid-acting or ultra-short acting
2. short-acting
3. intermediate-acting
4. long-acting
5. pre-mixed insulin
Rapid acting insulin Given 10-15 minutes prior to eating a meal
Must eat immediately after administration
Used to reduce BGL post a meal - acts most like endogenous insulin
Administered in conjunction with an intermediate or long acting insulin
Clear in appearance
The endocrine system Glands secrete hormones that regulate processes such as growth, reproduction,
and nutrient use (metabolism) by body cells.
Short-acting insulin Given 30 minutes prior to eating a meal
Used to reduce BGL post a meal
Administered in conjunction with an intermediate or long acting insulin
Clear in appearance
, NRSG265 exam
Intermediate acting insulin These are considered basal (background insulins)
Maintains glycaemic control once the rapid- or short-acting insulins are depleted
Does not need to be given with food
Cloudy in appearance - mix well prior to use
Long-acting insulin Slow and steady release of insulin
Administered once or twice daily
Does not need to be given with food
Clear in appearance
Mixed insulin Combination of rapid- or short-acting and intermediate-acting insulin
The insulin has an onset of the rapid- or short-acting insulin, and will last the
duration of the intermediate-acting insulin
type 2 diabetes mellitus diabetes in which either the body produces insufficient insulin or insulin resistance
(a defective use of the insulin that is produced) occurs; the patient usually is not
dependent on insulin for survival
Insulin for T2 DM Take this due to
· Acute illness or stress leading to an increased need for insulin (surgery,
pregnancy, physical stress, emotional stress);
· Oral hypoglycaemic agents become less effective in maintaining normal BGL over
time;
· Over time, in this the pancreas becomes unable to produce sufficient insulin due to
the increasing insulin resistance. This will require insulin to maintain glycaemic
control;
· Non-adherence to diet and exercise can lead to persistent hyperglycemia that only
insulin can control.
T2 DM risk factors · Genetic factors and family history
· Overweight and obese
· Sedentary lifestyle
· Age >35 and overweight
· ATSI, Indian subcontinent, pacific islander or Chinese background
· History of gestational diabetes
· Many modifiable risk factors
T2 DM pathophysiology Characterised by insulin resistance due to the following:
- Increased insulin resistance at the cell
- Reduction in the number of insulin binding sites
- Decrease in the amount of insulin binding to the receptors
- Decrease beta cell responsiveness to increased glucose levels
Initial signs and symptoms of T2DM · 3 Ps - polyphagia (increased appetite), Polyuria (increased urine output) and
polydipsia (increased thirst)
· Fatigue
· Hyperglycaemia
Late signs and symptoms of T2DM · Repeated infections
· Poor wound healing
· Blurred vision
· Weight changes
Mangement for T2DM 1. first line management
2. oral hypoglycaemic agents
3. holistic approach
Treatment for T2DM 1. Diet
2. Exercise
3. Close monitoring of BGL
a. Target 6-6mmol/L fasting
4. Oral hypoglycaemic agents (OHA) or insulin
5. Prevention of short- and long-term complications of DM
, NRSG265 exam
Hypoglycaemia Defined as a BGL < 4mmol/L Can be FATAL (low blood sugar levels)
Causes of hypoglycaemia · Medication overdose (OHA or insulin)
· Not eating enough carbohydrates or skipping meals
· Excess alcohol consumption
· Excessive exercise
· Malnutrition
Early signs and symptoms of hypoglycaemia · BGL < 4 mmol/L
· Trembling
· Sweating
· Pale
· Skin - cool, pale & clammy
· Hunger
· Headache
· Dizziness
Later signs and symptoms of hypoglycaemia · Difficulty concentrating
· Vision changes
· Anxiety
· Seizures
· Altered conscious state/unconsciousness
· Coma
· Death
Management of mild hypoglycemia 1. Check BGL < 4 mmol/L
2. Eat 15-20 grams of fast acting carbohydrates
3. Recheck BGL >4 mmol/L
4. Followed by 20 grams of slow acting carbohydrates
Management of severe hypoglycemia · If the person is unconscious, drowsy or not able to swallow, do not give them
anything to eat or drink
· Medical emergency!
1. Call for help
2. Position patient on their side, ensuring airway is clear – WHY?
3. IV dextrose bolus
4. If no IV access, administer IM glucagon (can cause vomiting) then IV dextrose as
soon as possible
5. Once patient is stabilised and able to eat and drink, follow up with 20 grams of
slow acting carbohydrates
Hyperglycaemia high blood glucose concentration
Complications of type 1 DM 1. Diabetic ketoacidosis (DKA)
2. higher rate of other autoimmune disease
Diabetic Ketoacidosis · Very serious medical condition related to hyperglycaemia, which gradually
develops over hours - days
· Due to lack of insulin leading to glucose build up in the blood
Risk factors:
1. New diagnosis
2. Acute stress or illness
3. Omission of insulin
4. Lack of access to medical care
DKA clinical manifestations Laboratory markers:
· BGL >11mmol/L
· Ketones present in blood and urine
· pH <7.3, HCO3- <15mmol/L
· K+ and Na+ changes
· High serum osmolarity
, NRSG265 exam
DKA - management 1. Correction of dehydration:
· Fluid resuscitation → cerebral oedema risk
· IVF - 24-72 hours
2. Reverse ketosis:
· Insulin infusion
· Dextrose infusion with/without KCl
3. Acid-base and electrolyte corrections:
· Regular 1/24 BGLs and 1-4/24 ABGs
· Urine ketones
· Close monitoring of U&Es (Na+ and K+ )
· Nurse pt 30°
· NBM
· Strict bed rest
· Strict FBC
· Cardiac monitoring
· Treat underlying cause
· Reintroduction of fluids and SC insulin once DKA resolved and significant clinical
improvement
Complications of Type 2 DM Hyperosmolar hyperglycaemic state (HHS)
Hyperosmolar hyperglycaemic state (HHS) Complication arising from Type 2 diabetes, often seen at initial presentation
Develops over days to weeks → dehydration and metabolic disturbances are more
severe
Characteristics of HHS · Severe hyperglycaemia
· Severe dehydration, hypovolaemia
· High serum osmality
· Very unwell
· No significant ketoacidosis
· Less common than DKA, but higher mortality rate 5-10%
Risk factors/causes of HHS · Elderly - reduced thirst or fluid intake
· Non-compliance or missed doses
· Poorly controlled Type 2 diabetes
· Infection and illness (MI, stroke, sepsis)- hyperglycaemia
· Drugs that reduce insulin action (glucocorticoids)
HHS lab markers · BGL > 30mmol/L
· Ketones can be present/absent
· pH > 7.3, HCO3- >15mmol/L
· K+ and Na+ changes
· High serum osmolality
Earlier signs and symptoms of HHS · Polyuria +
· Polydipsia +
Later signs and symptoms of HHS · Sunken eyes
· Tachycardia
· Hypotension
· Dry skin
· Headache
· Weakness
· Cramps
· Fatigue and lethargy
· Abdominal pain, N+V
· Seizures
· Altered LOC
· Coma
HHS - management IVF, Insulin infusions, regular BGLS, urine ketones, NBM, strict FBC.
