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Diabetes mellitus (DM) or simply diabetes, is a chronic health condition in which the body either fails to
produce sufficient amount of insulin or responds abnormally to insulin. Speaking about the
classification of diabetes mellitus, it is of three types, namely, Type 1 diabetes, Type 2 diabetes and
Gestational diabetes. The ultimate outcome for all three types of diabetes is high blood glucose level or
hyperglycemia. The pathophysiology of diabetes mellitus is very complex, as the disease is
characterized by different etiologies but share similar signs, symptoms and complications.


 


 
  



The pathophysiology of diabetes mellitus (all types) is related to the hormone insulin, which is secreted
by the beta cells of the pancreas. This hormone is responsible for maintaining glucose level in the
blood. It allows the body cells to use glucose as a main energy source. However, in a diabetic person,
due to abnormal insulin metabolism, the body cells and tissues do not make use of glucose from the
blood, resulting in an elevated level of blood glucose or hyperglycemia. Over a period of time, high
glucose level in the bloodstream can lead to severe complications, such as eye disorders, cardiovascular
diseases, kidney damage and nerve problems.

In Type 1 diabetes, the pancreas cannot synthesize enough amount of insulin hormone as required by
the body. The pathophysiology of Type 1 diabetes mellitus suggests that it is an autoimmune disease,
in which the body's own immune system generates secretion of substances that attack the beta cells of
the pancreas. Consequently, the pancreas secretes little or no insulin. Type 1 diabetes is more common
among children and young adults (around 20 years). Since it is common among young individuals and
insulin hormone is used for treatment, Type 1 diabetes is also referred to as Insulin Dependent Dabetes
Mellitus (IDDM) or Juvenile Diabetes.

In case of Type 2 diabetes mellitus, there is normal production of insulin hormone but the body cells are
resistant to insulin. Since the body cells and tissues are non responsive to insulin, glucose remains in the
bloodstream. It is commonly manifested by middle-aged adults (above 40 years). As insulin is not
necessary for treatment of Type 2 diabetes, it is known as Non-insulin Dependent Diabetes Mellitus
(NIIDM) or Adult Onset Diabetes.

Gestational diabetes, on the other hand, occurs among pregnant women. It is caused due to
fluctuations of the hormonal level during pregnancy. Usually, the blood glucose level returns to normal
after the baby is born.

As already mentioned above, the symptoms and effects of all the three forms of diabetes are similar.
The noticeable manifested symptoms include increased thirst (polydipsia), increased urination
(polyuria), increased appetite (polyphagia), excessive fatigue, unexplained weight loss and body
irritation. Regarding the definition of diabetes mellitus, it is often described as a fasting blood glucose
level of 126 milligrams per deciliter (mg/dL) or more. As per statistics, Type 2 diabetes is the most
commonly occurring type, in comparison to the other two forms of diabetes mellitus.

Early and correct detection of the type of diabetes is necessary to prevent severe health effects. After
diagnosis, a physician may prescribe appropriate medication for treatment of diabetes, which could
include insulin injections or oral insulin medicines, depending upon the type of diabetes mellitus. In
addition, healthy lifestyle modifications, especially diet and exercise are recommended for the effective
management of symptoms and long-term effects. Since diabetes is a global health issue, studies
regarding the pathophysiology of diabetes mellitus are currently in progress in order to minimize its
associated health effects.
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Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells
stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed
into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and
hunger. The treatment includes changes in diet, oral medications, and in some cases, daily
injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset
diabetes, and this form of diabetes occurs most often in people who are overweight and who do
not exercise. Type II is considered a milder form of diabetes because of its slow onset
(sometimes developing over the course of several years) and because it usually can be controlled
with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes,
however, are the just as serious as those for Type I. This form is also called noninsulin-
dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can
control the condition with diet and oral medications, however, insulin injections are sometimes
necessary if treatment with diet and oral medication is not working.

The causes of diabetes mellitus are unclear, however, there seem to be both hereditary (genetic
factors passed on in families) and environmental factors involved. Research has shown that some
people who develop diabetes have common genetic markers. In Type I diabetes, the immune
system, the body¶s defense system against infection, is believed to be triggered by a virus or
another microorganism that destroys cells in the pancreas that produce insulin. In Type II
diabetes, age, obesity, and family history of diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells have become
resistant to the insulin produced and it may not work as effectively. Symptoms of Type II
diabetes can begin so gradually that a person may not know that he or she has it. Early signs are
lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight
loss, slow wound healing, urinary tract infections, gum disease, or blurred vision. It is not
unusual for Type II diabetes to be detected while a patient is seeing a doctor about another health
concern that is actually being caused by the yet undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include people who:

O are obese (more than 20% above their ideal body weight)
O have a relative with diabetes mellitus
O belong to a high-risk ethnic population (African-American, Native American, Hispanic,
or Native Hawaiian)
O have been diagnosed with gestational diabetes or have delivered a baby weighing more
than 9 lbs (4 kg)
O have high blood pressure (140/90 mmHg or above)
O have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a
triglyceride level greater than or equal to 250 mg/dL
O have had impaired glucose tolerance or impaired fasting glucose on previous testing
Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle
changes. It is best managed with a team approach to empower the client to successfully manage
the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the
various health disciplines involved; provides care and education and promotes the client¶s health
and well being. Diabetes is a major public health worldwide. Its complications cause many
devastating health problems.

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Every cell in the human body needs energy in order to function. The body¶s primary energy
source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates
(sugars and starches). Glucose from the digested food circulates in the blood as a ready energy
source for any cells that need it. Insulin is a hormone or chemical produced by cells in the
pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of
cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of
the glucose can be converted to concentrated energy sources like glycogen or fatty acids and
saved for later use. When there is not enough insulin produced or when the doorway no longer
recognizes the insulin key, glucose stays in the blood rather entering the cells.

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Several blood tests are used to measure blood glucose levels, the primary test for diagnosing
diabetes. Additional tests can determine the type of diabetes and its severity.

O Random blood glucose test ² for a random blood glucose test, blood can be drawn at
any time throughout the day, regardless of when the person last ate. A random blood
glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of
high blood glucose (see ³Symptoms´ above) suggests a diagnosis of diabetes.

O †asting blood glucose test ² fasting blood glucose testing involves measuring blood
glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal
 fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL
(7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of
blood from a vein or fingertip. It must be repeated on another day to confirm that it
remains abnormally high (see ³Criteria for diagnosis´ below).

O Hemoglobin A1C test (A1C) ² The A1C blood test measures the average blood glucose
level during the past two to three months. It is used to monitor blood glucose control in
people with known diabetes, but is not normally used to diagnose diabetes. Normal
values for A1C are 4 to 6 percent (show figure 3). The test is done by taking a small
sample of blood from a vein or fingertip.

O Oral glucose tolerance test ² Oral glucose tolerance testing (OGTT) is the most sensitive
test for diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely
recommended because it is inconvenient compared to a fasting blood glucose test.

The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram
liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two
hours later, a second blood glucose level is measured.

Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen

for gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose
level drawn one hour later. †or women who have an abnormally elevated blood glucose level, a
second OGTT is performed on another day after drinking a 100 gram glucose solution. The
blood glucose level is measured before, and at one, two, and three hours after drinking the
solution.

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When diet, exercise and maintaining a healthy weight aren¶t enough, you may need the help of
medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes
and some people with type 2 diabetes must take insulin every day to replace what their pancreas
is unable to produce. Unfortunately, insulin can¶t be taken in pill form because enzymes in your
stomach break it down so that it becomes ineffective. †or that reason, many people inject
themselves with insulin using a syringe or an insulin pen injector,a device that looks like a pen,
except the cartridge is filled with insulin. Others may use an insulin pump, which provides a
continuous supply of insulin, eliminating the need for daily shots.

The most widely used form of insulin is synthetic human insulin, which is chemically identical to
human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isn¶t
perfect. One of its chief failings is that it doesn¶t mimic the way natural insulin is secreted. But
newer types of insulin, known as insulin analogs, more closely resemble the way natural insulin
acts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine
(Lantus).

A number of drug options exist for treating type 2 diabetes, including:

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 These medications stimulate your pancreas to produce and release more
insulin. †or them to be effective, your pancreas must produce some insulin on its own. Second-
generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta,
Glynase PresTab, Micronase) and glimepiride (Amaryl) are prescribed most often. The most
common side effect of sulfonylureas is low blood sugar, especially during the first four months
of therapy. You¶re at much greater risk of low blood sugar if you have impaired liver or kidney
function.

â  These medications, such as repaglinide (Prandin), have effects similar to
sulfonylureas, but you¶re not as likely to develop low blood sugar. Meglitinides work quickly,
and the results fade rapidly.

â  Metformin (Glucophage, Glucophage XR) is the only drug in this class available
in the United States. It works by inhibiting the production and release of glucose from your liver,
which means you need less insulin to transport blood sugar into your cells. One advantage of
metformin is that is tends to cause less weight gain than do other diabetes medications. Possible
side effects include a metallic taste in your mouth, loss of appetite, nausea or vomiting,
abdominal bloating, or pain, gas and diarrhea. These effects usually decrease over time and are
less likely to occur if you take the medication with food. A rare but serious side effect is lactic
acidosis, which results when lactic acid builds up in your body. Symptoms include tiredness,
weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is especially likely to occur if
you mix this medication with alcohol or have impaired kidney function.

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 These drugs block the action of enzymes in your digestive tract
that break down carbohydrates. That means sugar is absorbed into your bloodstream more
slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal.
Drugs in this class include acarbose (Precose) and miglitol (Glyset). Although safe and effective,
alpha-glucosidase inhibitors can cause abdominal bloating, gas and diarrhea. If taken in high
doses, they may also cause reversible liver damage.

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 These drugs make your body tissues more sensitive to insulin and keep
your liver from overproducing glucose. Side effects of thiazolidinediones, such as rosiglitazone
(Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight gain and fatigue. A
far more serious potential side effect is liver damage. The thiazolidinedione troglitzeone
(Rezulin) was taken off the market in March 2000 because it caused liver failure. If your doctor
prescribes these drugs, it¶s important to have your liver checked every two months during the
first year of therapy. Contact your doctor immediately if you experience any of the signs and
symptoms of liver damage, such as nausea and vomiting, abdominal pain, loss of appetite, dark
urine, or yellowing of your skin and the whites of your eyes (jaundice). These may not always be
related to diabetes medications, but your doctor will need to investigate all possible causes.

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  By combining drugs from different classes, you may be able to control
your blood sugar in several different ways. Each class of oral medication can be combined with
drugs from any other class. Most doctors prescribe two drugs in combination, although
sometimes three drugs may be prescribed. Newer medications, such as Glucovance, which
contains both glyburide and metformin, combine different oral drugs in a single tablet.
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O Advice patient about the importance of an individualized meal plan in meeting weekly
weight loss goals and assist with compliance.
O Assess patients for cognitive or sensory impairments, which may interfere with the ability
to accurately administer insulin.
O Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient
to achieve mastery of technique by taking step by step approach.
O Review dosage and time of injections in relation to meals, activity, and bedtime based on
patients individualized insulin regimen.
O Instruct patient in the importance of accuracy of insulin preparation and meal timing to
avoid hypoglycemia.
O Explain the importance of exercise in maintaining or reducing weight.
O Advise patient to assess blood glucose level before strenuous activity and to eat
carbohydrate snack before exercising to avoid hypoglycemia.
O Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses,
dryness, hair distribution, pulses and deep tendon reflexes.
O Maintain skin integrity by protecting feet from breakdown.
O Advice patient who smokes to stop smoking or reduce if possible, to reduce
vasoconstriction and enhance peripheral flow.

Type 1



 is a chronic metabolic disorder caused by an absolute or relative
deficiency of insulin, an anabolic hormone.
 
 diabetes mellitus can occur at any age and is
characterized by the marked and progressive inability of the pancreas to secrete insulin because
of autoimmune destruction of the beta cells. It commonly occurs in children, with a fairly abrupt
onset; however, newer antibody tests have allowed for the identification of more people with the
new-onset adult form of type 1 diabetes mellitus called „

 
 


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. The distinguishing characteristic of a patient with type 1 diabetes is that, if his or her
insulin is withdrawn, ketosis and eventually ketoacidosis develop. Therefore, these patients are
dependent on exogenous insulin.

 

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       accounts for 5%
to 10% of all people with diabetes. In type 1 diabetes, the body¶s immune system destroys the
cells that release insulin, eventually eliminating insulin production from the body. Without
insulin, cells cannot absorb sugar (glucose), which they need to produce energy.

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O Extreme thirst
O frequent urination
O drowsiness
O lethargy
O increased appetite
 O sudden weight loss for no reason
O sudden vision changes
O sugar in urine
O ketones in urine
O heavy or laboured breathing
O unconsciousness

 


 occurs when the pancreas produces insufficient amounts of the
hormone insulin and/or the body¶s tissues become resistant to normal or even high levels of
insulin. This causes high blood glucose (sugar) levels, which can lead to a number of
complications if untreated.

 

 is a chronic medical condition that requires regular monitoring and treatment.
Treatment, which includes lifestyle adjustments, self-care measures, and sometimes medications,
can control blood glucose levels in the near-normal range and minimize the risk of diabetes-
related complications.

 

 accounts for around 85% of all people with diabetes.

  

O Any symptoms of DM Type 1

O recurring or hard-to heal skin, gum or urinary tract infections
O drowsiness
O tingling of hands and feet
O itching of skin and genitals