________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Insulin Therapy (cont.)
• Insulin pump
• Needle is inserted subcutaneously in an appropriate part of the anatomy
TALKING POINTS:
• Consists of a battery–driven syringe with a long piece of tubing (usually made of Teflon)
that is attached to a small needle.
• One advantage of the external insulin pump is that patients do not have to use
intermediate- or long-acting insulins, with their uncertain peaks and valleys.
• What is an “artificial pancreas?”
Slide 38
Oral Hypoglycemic Agents
• If patients with type 2 DM unable to control blood glucose with nutrition and exercise,
provider may prescribe oral hypoglycemics
• Sulfonylureas (three generations), alpha-glucosidase inhibitors, biguanides,
thiazolidinediones,
D-phenylalanines, meglitinides
• Dipeptidyl peptidase-4 inhibitor agents
TALKING POINTS:
• What interventions may be required if the blood glucose rises above 200 mg/dL?
Slide 39
Injectable Medications to Treat Diabetes
• Pramlintide slows gastric emptying and suppresses appetite
• Exenatide lowers blood glucose levels by increasing insulin secretion, suppressing
postprandial glucagon secretion, slows gastric emptying, suppressing the appetite
• Complex dosing schedules requiring injections before each meal
• Expensive; not covered by many insurance companies
• Another noninsulin injection, Liraglutide, stimulates insulin production while suppressing
hepatic glucose output, helps with weight loss
Slide 40
Self-Monitoring of Blood Glucose
• Allows patients to monitor blood glucose levels to regulate diet, exercise, and medication
regimen to remain euglycemic
• Portable electronic glucose meters have largely replaced other methods of
self-monitoring
TALKING POINTS:
• The self-monitoring of blood glucose levels is seen as the greatest breakthrough in
managing diabetes since the advent of insulin.
• What should premeal plasma glucose levels be? Bedtime glucose levels?
18 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 41
Glycosylated Glucose Levels
• Glycosylated hemoglobin (HbA1c) reflects glucose levels over the past few months
• Fructosamine levels reflect those over several weeks
Slide 42
Complications of Therapy
• Hypoglycemia
• If person injects too much insulin, does not eat enough, eats at the wrong time, or
exercises inconsistently, glucose levels may suddenly drop
TALKING POINTS:
• The Somogyi phenomenon should be suspected when a patient reports awakening with
a headache, and complains of restless sleep, nightmares, enuresis (involuntary voiding
during sleep), and nausea and vomiting.
• How can the Somogyi phenomenon be confirmed?
8
Slide 43
Assessment
• Ketoacidosis: ketonuria, Kussmaul respirations, orthostatic hypotension, hypertension,
nausea, vomiting, lethargy, or change in level of consciousness
• Hypoglycemic patient: expect to find tachycardia, anxiety, trembling, and decreasing
level of consciousness
• Be alert for indications of hyperosmolar nonketotic coma
Slide 44
Assessment (cont.)
• Attempt to determine the following
• Type of diabetes
• Hypoglycemic agents: name, dosage, when last dose was taken
• Food and fluid intake for the past 3 days
• Relevant laboratory values: blood glucose, blood pH, bicarbonate levels, electrolytes,
and osmolality and urine osmolality
Slide 45
Health History
• Chief complaint and history of present illness
• Signs/symptoms that prompted patient to seek medical care
• Medical history
• Type and duration of DM
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 46
Health History (cont.)
• Review of systems
• Description of the patient’s general health
• Changes in skin moisture or turgor
• Inquire whether the patient has had floaters, diplopia (double vision), or blurred
• Changes in mental alertness or seizures
Slide 47
Health History (cont.)
• Functional assessment
• Explore factors that can affect patient’s ability to perform self-care, including literacy,
financial resources such as health insurance, and family support
TALKING POINTS:
• Why would a patient be asked for a 24-hour dietary history?
Slide 48
Health History (cont.)
• Physical examination
• Level of consciousness, posture and gait, and apparent well-being
• Vital signs, height, and weight
• Skin color, warmth, turgor, and lesions noted
• Inspect eyegrounds for evidence of diabetic retinopathy or cataracts
Slide 49
• Ineffective coping
Interventions
• Ineffective health maintenance
• Ineffective family therapeutic regimen management
• Risk for deficient fluid volume
• Risk for injury
20 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
1
Slide 50
Hypoglycemia: Pathophysiology
• Develops when the blood glucose level falls to less than 45 to 50 mg/dL
• Symptoms occur at different blood levels according to individual tolerances and how
rapidly the level falls
TALKING POINTS:
• Hypoglycemia may result from causes other than the pharmacologic treatment for
diabetes.
Slide 51
Causes
• Exogenous hypoglycemia
• outside factors acting on the body to produce a low blood glucose
• Include insulin, oral hypoglycemic agents, alcohol, or exercise
4
Slide 52
Signs and Symptoms
• Glucose level falls rapidly, causes epinephrine, cortisol, glucagon, and growth hormone
to be secreted in an attempt to increase glucose levels
• Symptoms: weakness, hunger, diaphoresis, tremors, anxiety, irritability, headache,
pallor, and tachycardia
9
Slide 53
Medical Diagnosis
• The diagnosis of hypoglycemia not associated with diabetes can be based on fasting
blood glucose, OGTT, intravenous glucose tolerance test, and 72-hour inpatient fasting
• Whipple’s triad
• The presence of symptoms
• Documentation of low blood glucose when symptoms occur
• Improvement of symptoms when blood glucose rises
10
Medical Treatment
• In an unconscious patient who has diabetes, hypoglycemia should be suspected until it is
ruled out
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 55
Medical Treatment (cont.)
• Prevention of hypoglycemia by proper food intake
• The diet is directed by the underlying cause
• If overproduction of insulin after carbohydrate ingestion, a low-carbohydrate, high-
protein diet
TALKING POINTS:
• In an unconscious patient who has diabetes, hypoglycemia should be suspected until it is
ruled out.
• What is the recommended amount of carbohydrates per day?
8
Slide 56
Assessment
• Present illness: shakiness, nervousness, irritability, tachycardia, anxiety,
lightheadedness, hunger, tingling or numbness of the lips or tongue, nightmares, and
crying out during sleep
Slide 57
Assessment (cont.)
• Note hypoglycemic agents, prescribed dose, and the time last dose taken
• Functional assessment: information about current diet, exercise, alcohol intake, and the
effects of symptoms on daily activities
• Important aspects of the physical examination include general behavior, appearance,
pulse, and blood pressure
Slide 58
Interventions
• Deficient knowledge
• Risk for injury
• Ineffective self-health management
Slide 59
Question 1
• When insulin is absent, glucose cannot be transported from the bloodstream to the cells.
This causes the patient to experience _________.
A. polyuria
B. polydipsia
C. polyphagia
D. polyneuralgia
TALKING POINTS:
Introduction to Medical-Surgical Nursing, 6th ed.
Slide 60
Question 2
• Which of the following is not a risk factor for type 2 diabetes mellitus?
A. Emaciation
B. Sedentary lifestyle
C. Age 40 years and older
D. Cardiovascular disease and hypertension
Activities
Classroom Choose from below to make 30 minutes
Online
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the pathophysiology of diabetes
mellitus and describe the secretion of insulin
and how it affects blood glucose level.
• Lead a class discussion in which students
explain the meaning of exogenous and
endogenous in relation to insulin.
• Discuss the pathophysiology of
hypoglycemia, describing the exogenous,
endogenous, and functional causes of
hypoglycemia in adults.
PRACTICE
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to post a video of a nurse explaining the risk
factors for diabetes, along with some
suggestions to reduce the risk factors. Ask
students to provide constructive comments
on each other’s videos.
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 23
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
DISCUSS
• Discuss the difference between type 1 and
type 2 diabetes mellitus.
PRACTICE
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe how
you would explain to a patient the difference
between type 1 and type 2 diabetes mellitus.
DISCUSS
• Discuss the role of insulin in glucose
metabolism and the synthesis of fatty acids
and proteins.
PRACTICE
• Divide the class into small groups. Assign
each group a function of insulin in the body:
information to the class.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Conduct online
research to reveal the history of the
discovery of insulin. The students should
post their findings. Ask students to provide
constructive comments on each other’s
findings.
24 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
DISCUSS
• Discuss the signs and symptoms of diabetes
mellitus and define polydipsia, polyuria, and
polyphagia.
• Discuss the differences in the causes of type
1 and type 2 diabetes mellitus.
• Discuss risk factors for type 2 diabetes
PRACTICE
• Ask each student to choose a sign or
symptom of diabetes mellitus or
hypoglycemia. Have each student write a
short synopsis of the cause of that particular
mellitus and hypoglycemia.
• Facilitate a class discussion about
hypoglycemia. Have students identify the
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to prepare a video or online information
regarding the signs and symptoms of
diabetes. The video or online information
should be presented to an audience of
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 25
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
DISCUSS
• Discuss the microvascular complications of
diabetes mellitus and the incidence and
signs and symptoms of retinopathy and
nephropathy.
• Discuss the macrovascular complications of
diabetes mellitus.
• Discuss the neuropathic complications of
diabetes mellitus and define and describe
PRACTICE
• Divide the class into small groups, and
assign each group one of the following
complications associated with diabetes
mellitus:
• Long-term complications (e.g.,
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss which
complication of diabetes you would most
fear, if you had diabetes.
• Post the following discussion topic online
and have students comment. Assuring
confidentiality, ask students to discuss a
person they know who has diabetes. THIS
constructive comments on each other’s
postings.
26 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
DISCUSS
• Discuss acute hypoglycemia and describe
events that can trigger this complication,
along with signs and symptoms.
PRACTICE
• Divide the class into two groups. Have one
group develop a list of the signs and
symptoms of acute hypoglycemia and the
other group a list of the signs and symptoms
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Ask the
students to prepare a video of several
DISCUSS
• Discuss acute hypoglycemia (p. 1053).
PRACTICE
• Divide the class into two groups. Have one
group develop a list of the medical
treatments for acute hypoglycemia and the
POST AND COMMENT
• Post the following discussion topic online
hypoglycemia and its treatment as
compared to diabetic ketoacidosis. Ask
students to provide constructive comments
to each other’s videos.
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 27
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
DISCUSS
• Discuss the nursing assessment of a patient
PRACTICE
• Divide the class into small groups. Present
the following scenario to the class:
• A 44-year-old obese man is admitted
with a blood glucose level of 400 mg/dL
and a blood pH of 7.28. The patient
experienced increasing fatigue,
headaches, and weakness. He is
the class.
• Ask a diabetic clinical nurse specialist to
speak to the class. Ask the speaker to
• Divide the class into groups. Ask each group
to discuss a nursing care plan for the
following patient:
• A 75-year-old woman with diabetes
mellitus type 2 who receives insulin
POST AND COMMENT
• Post the following discussion topic online
hyperglycemia. Provide a token gift to the
group who receives most “Likes” on their
video.
28 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
DISCUSS
PRACTICE
POST AND COMMENT
including the test’s purpose, preparation,
and procedure. Then have the students post
DISCUSS
• Discuss nutritional management of diabetes
mellitus and highlight the need for weight
control and the proper balance of nutrients.
• Discuss oral hypoglycemic (antidiabetic)
agents and describe the actions and major
adverse effects for each class.
• Discuss hypoglycemia, the Somogyi
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to post a blog about their own dietary intake
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 29
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
PRACTICE
• As a class, discuss the treatment of
hypoglycemia for the following patients:
• Unconscious patient with known
diabetes mellitus
• Patient with diabetes mellitus is awake
DISCUSS
• Discuss nursing interventions for a patient
diagnosed with ketoacidosis.
Critical Thinking Question
A 56-year-old Hispanic woman is admitted to the hospital with diabetic ketoacidosis (DKA).
She does not have a previous diagnosis of diabetes mellitus. She is obese and states that
the only activities that she participates in are household chores. Why has this woman
developed DKA? What are her risk factors for diabetes mellitus? What can the patient do to
help control her diabetes mellitus?
Discussion Guidelines: DKA is a life-threatening complication of diabetes mellitus, which is
caused by deficiency of insulin in the body. Lack of insulin leads to elevated blood glucose levels,
losing weight and exercising, as well as by taking medications prescribed for this condition.
Instructor Notes/Student Feedback
30 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
48
Assessments for
Diabetes Mellitus and Hypoglycemia
CHAPTER OBJECTIVES
Lesson 48.1:
2. Explain the difference between type 1 and type 2 diabetes mellitus.
4. Describe the signs and symptoms of diabetes mellitus and hypoglycemia.
6. Differentiate between acute hypoglycemia and diabetic ketoacidosis.
8. Identify nursing interventions for a patient diagnosed with diabetes mellitus or hypoglycemia.
10. Discuss treatment of diabetes mellitus and hypoglycemia.
11. Identify nursing interventions for a patient diagnosed with ketoacidosis.
Assessments by Lesson & Objective
Lesson 48.1
1
Study Guide
• Part IA: 2, 1 (p. 319)
• Part IIH: 1, 30 (pp. 322-324)
Evolve Instructor Resources
Evolve Student Resources
• NCLEX Review: 6
2
Study Guide
• Part IA: 1, 3 (p. 319)
• Part III I: 1 (p. 324)
Evolve Instructor Resources
• Test Bank: 1, 2
• Open Book Quiz: 1
Evolve Student Resources
• NCLEX Review: 7
Study Guide
Evolve Student Resources
• NCLEX Review: 5, 10
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 31
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
4
Study Guide
• Part ID: 1 (p. 321)
• Part IIH: 14 (p. 323)
Evolve Instructor Resources
Evolve Student Resources
• NCLEX Review: 8
5
Study Guide
• Part IB: 1-20 (p. 320)
Evolve Instructor Resources
• Test Bank: 4, 27-29
• Open Book Quiz: 3
Evolve Student Resources
• NCLEX Review: 2
6
Study Guide
Evolve Instructor Resources
• Test Bank: 9-11, 25
7
Study Guide
• Part IC: 1, 3 (p. 320)
• Part IIH: 23 (p. 324)
Evolve Instructor Resources
• Test Bank: 8, 16, 22
• Open Book Quiz: 4, 10
8
Study Guide
Evolve Instructor Resources
• Test Bank: 6, 12, 13, 17-20, 26
Evolve Student Resources
• NCLEX Review: 9
• Prioritization: 1, 5
32 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
9
Study Guide
• Part IF: 1-3 (p. 321)
• Part IIH: 3, 4 (p. 322)
Evolve Instructor Resources
Evolve Student Resources
• NCLEX Review: 1
• Prioritization: 2
10
Study Guide
Evolve Instructor Resources
• Test Bank: 8, 12
• Open Book Quiz: 5-8
Evolve Student Resources
• NCLEX Review: 3, 4
• Prioritization: 3, 4
Study Guide
Instructor’s Notes/Student Feedback