Introduction to Medical-Surgical Nursing, 6th ed.
48
Lesson Plans for
Diabetes Mellitus and Hypoglycemia
CHAPTER LESSON PLANS & 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. Assist in developing a nursing care plan for a patient with diabetes mellitus and hypoglycemia.
CHAPTER TEACHING FOCUS
• In this chapter, the student will be introduced to topics related to diabetes mellitus and hypoglycemia.
• The student will have the opportunity to become acquainted with the pathophysiology, signs and
symptoms, diagnostic tests and procedures, and treatment of diabetes mellitus and hypoglycemia.
• Nursing care of the patient with diabetes mellitus and hypoglycemia, including assessment and
interventions, will also be discussed.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Homeostasis and Regulation
• Concept: Glucose Regulation
• Exemplar: Diabetes Mellitus, p. 1058
• Box 48-1: Insulin: Actions and Effects of Deficiency, p. 1059
• Figure 48-1: Possible Immunologic cause of diabetes mellitus (DM), p. 1060
• Cultural Considerations: What Does Culture Have to Do with Diabetes? p. 1060
• Pharmacology Capsule, p. 1060
• Cultural Considerations: What Does Culture Have to Do with Nephropathy? p. 1060
• Patient Teaching: “Dos and Do Nots” Regarding Foot Care, p. 1063
• Complementary and Alternative Therapies, p. 1064
• Recommendations for Glycemic, Blood Pressure, and Lipid Control for Adults with Diabetes, p.
1064
• Pharmacology Capsule, p. 1065
2 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
• Figure 48-2: Effect of insulin on blood glucose levels, p. 1070
• Pharmacology Capsule, p. 1071
• Pharmacology Capsule, p. 1071
• Figure 48-3: Insulin injection sites, p. 1072
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 3
Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) Insulin that is produced by a person’s body is __________.
a) exogenous
b) genetic
c) endogenous
d) synthetic
2) Excessive glucose in the bloodstream increases its osmolality, which initially causes the patient to
experience __________.
a) polyphagia
b) polyuria
c) hypoglycemia
d) polydipsia
3) People of which cultural background are the most likely to develop diabetes mellitus?
a) African-American
b) Hispanic
c) Asian
d) European
4) Diabetes mellitus is the leading cause of which of the following disorders?
a) End-stage renal disease
b) Cancer
c) Rheumatoid arthritis
d) Gangrene
5) Which of the following blood glucose levels is considered moderate hypoglycemia?
a) 40 mg/dL
b) 55 mg/dL
c) 75 mg/dL
d) 100 mg/dL
6) The appropriate treatment for a hospitalized unconscious patient with hypoglycemia would be
__________.
a) 6 ounces of orange juice
b) a piece of candy
c) an intramuscular injection of glucagon
d) putting sugar under the tongue to dissolve
7) The most likely cause of diabetic ketoacidosis (DKA) is __________.
a) overeating
b) taking too much insulin
c) not taking enough insulin
d) drinking alcohol
8) One of the primary goals in treating diabetes mellitus is __________.
a) gaining weight
b) decreasing insulin use
c) stabilizing glucose levels
d) treating complications
9) Which of the following is an example of intermediate-acting insulin?
a) Lispro
b) Regular insulin
c) Ultralente
d) NPH insulin
10) Hypoglycemia caused by drinking alcohol on an empty stomach is considered a(n) __________.
a) exogenous cause
b) endogenous cause
c) functional cause
d) natural cause
4 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
1) c
6) c
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: What are three types of diabetes mellitus? Explain the differences in each type of diabetes
mellitus.
Answer: Three types of diabetes mellitus are type 1, type 2, and gestational diabetes mellitus. Type 1
Question: What are three common complications of diabetes mellitus? Explain the cause of the
complications.
Answer: Three of the most common complications of both type 1 and type 2 diabetes mellitus are heart
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Instructor Preparation
Textbook Objectives Covered
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. Assist in developing a nursing care plan for a patient with diabetes mellitus and hypoglycemia.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: diabetic clinical nurse specialist
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying diabetes mellitus and hypoglycemia, including:
• The role of insulin in the body
• Pathophysiology of diabetes mellitus and hypoglycemia
• Signs and symptoms
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• endogenous (p. 1058)
• exogenous (p. 1059)
• glycosuria (p. 1061)
• hyperglycemia (p. 1058)
• hypoglycemia (p. 1062)
• ketoacidosis (p. 1064)
• neuropathy (p. 1062)
• polydipsia (p. 1059)
• polyphagia (p. 1059)
• polyuria (p. 1059)
• retinopathy (p. 1061)
6 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 1058-1059)
REVIEW
• Figure 48-1: Possible immunologic cause of diabetes mellitus (p. 1060)
ANSWER – Text
• Review Questions for the NCLEX Examination: 2 (p. 1087)
ANSWER – Study Guide
• Part IA: 2, 1 (p. 319)
• Part IIH: 1, 30 (pp. 322-324)
2
READ – Textbook (pp. 1058-1059)
ANSWER – Study Guide
• Part IA: 1, 3 (p. 319)
• Part III I: 1 (p. 324)
3
READ – Textbook (pp. 1059-1061)
REVIEW
• Box 48-1: Insulin: Actions and Effects of Deficiency (p. 1059)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1 (p. 1087)
ANSWER – Study Guide
• Part IA: 4, 6, 7 (p. 319)
• Part IE: 1-10 (p. 321)
4
• Part ID: 1 (p. 321)
READ – Textbook (pp. 1064-1066, 1084-1086)
ANSWER – Text
• Review Questions for the NCLEX Examination: 9 (p. 1087)
ANSWER – Study Guide
5
READ – Textbook (pp. 1061-1064)
ANSWER – Text
• Review Questions for the NCLEX Examination: 3, 4, 10 (p. 1087)
ANSWER – Study Guide
• Part IB: 1-20 (p. 320)
• Part IIH: 22 (p. 324)
• Part III I: 2, 3, 9 (pp. 324-325)
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 7
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
6
READ – Textbook (pp. 1064-1066, 1084-1086)
REVIEW
• Table 48-4: Exogenous, Endogenous, and Functional Causes of Hypoglycemia (p. 1085)
ANSWER – Text
• Review Questions for the NCLEX Examination: 5 (p. 1087)
ANSWER – Study Guide
• Part IC: 2, 4-8 (pp. 320-321)
• Part IIH: 2, 11, 17-19, 21, 29, 31 (pp. 322-324)
• Part III I: 4, 5 (p. 325)
7
READ – Textbook (pp. 1064-1066, 1084-1086)
ANSWER – Study Guide
• Part IC: 1, 3 (p. 320)
• Part IIH: 23 (p. 324)
8
READ – Textbook (pp. 1066-1086)
• Box 48-2: Assessment of the Patient with Diabetes Mellitus (p. 1078)
ANSWER – Study Guide
• Part IIH: 10, 15, 16, 24-27 (pp. 323-324)
• Part III I: 11 (pp. 325-326)
• Part IIIJ: 1-8 (pp. 326-327)
9
READ – Textbook (p. 1066)
ANSWER – Study Guide
• Part IF: 1-3 (p. 321)
• Part IIH: 3, 4 (p. 322)
10
READ – Textbook (pp. 1066-1086)
REVIEW
• Table 48-1: Drug Therapy: Insulin Preparations: Time Course of Action (p. 1070)
• Figure 48-2: Effect of insulin on blood glucose levels (p. 1070)
ANSWER – Text
• Review Questions for the NCLEX Examination: 6, 7, 8 (p. 1087)
ANSWER – Study Guide
• Part IE: 11-18 (p. 321)
• Part IIH: 5-7, 9, 12, 13, 20 (pp. 322-323)
• Part III I: 6, 7 (p. 325)
8 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
11
READ – Textbook (pp. 1078-1084, 1086)
REVIEW
• Box 48-2: Assessment of the Patient with Diabetes Mellitus (p. 1078)
• Nursing Care Plan 48-1: Patient with Type 1 Diabetes Mellitus (pp. 1080-1081)
• Nursing Care Plan 48-2: Patient with Type 2 Diabetes Mellitus (pp. 1081-1083)
•
• ANSWER – Study Guide
• Part IIH: 11 (p. 323)
• Part III I: 8, 10 (p. 325)
• Part IIIJ: 1, 2, 3, 6, 7, 8 (pp. 326-327)
SIMCHART
• Scenario 7: Carl Rogers: Diabetic Wound Care and Insulin Administration
Lecture Outline 20 minutes
Slide 1
Chapter 48
Diabetes Mellitus and Hypoglycemia
1
&
2
Slide 2
Pathophysiology
• Chronic disorder of impaired metabolism with vascular and neurologic complications
• Key feature is elevated blood glucose, called hyperglycemia
• Blood glucose level normally regulated by insulin, a hormone produced by beta cells
in the islets of Langerhans located in the pancreas
TALKING POINTS:
Slide 3
Type 1
• Absence of endogenous insulin
• Formerly called juvenile-onset diabetes because it most commonly occurs in
juveniles and young adults
• An autoimmune process, possibly triggered by a viral infection, destroys beta cells, the
development of insulin antibodies, and the production of islet cell antibodies (ICAs)
• Affected people require exogenous insulin for the rest of their lives
Slide 4
Type 2
• Inadequate endogenous insulin and body’s inability to properly use insulin
• Beta cells respond inadequately to hyperglycemia; results in chronically elevated blood
glucose
• Continuous high glucose level in the blood desensitizes the beta cells; they become less
responsive to the elevated glucose
• More common in adults; increasing in children
• Controlled by diet and exercise; may require oral hypoglycemic agents or exogenous
insulin
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
3
Slide 5
• Osmotic force created by glucose draws extra fluid and electrolytes with it, causing
Role of Insulin
• Glucose
• Insulin stimulates active transport of glucose into cells
• If insulin absent, glucose remains in the bloodstream
• Blood becomes thick, which increases its osmolality
• Increased osmolality stimulates the thirst center
TALKING POINTS:
• The patient may take in more food but, unfortunately, cannot use the extra glucose
without insulin.
• Weight loss occurs despite increased appetite and food ingestion.
• What are the three “Ps” related to symptoms of DM?
Slide 6
Role of Insulin (cont.)
• Fatty acids
• Promotes fatty acid synthesis and conversion of fatty acids into fat, which is stored
as adipose tissue
• Also spares fat by inhibiting breakdown of adipose tissue and mobilization of fat and
by inhibiting the conversion of fats to glucose
• Without adequate insulin, fat stores break down and increased triglycerides are
stored in the liver
• Increased fatty acids in the liver can triple the production of lipoproteins; promotes
atherosclerosis
TALKING POINTS:
• Why do people with DM have a high incidence of cardiovascular disease?
Slide 7
Role of Insulin (cont.)
• Protein
• Enhances protein synthesis in tissues and inhibits the conversion of protein into
glucose
• Amino acids are admitted into cells; enhances rate of protein formation while
3
Slide 8
Cause
• An autoimmune malfunction may cause complete destruction of the islets of Langerhans
in the pancreas, creating type 1 diabetes
• Islet cell antibodies are identified in more than 80% of all people with type 1 diabetes at
the time of diagnosis
10 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 9
Risk Factors
• Obesity
• Sedentary lifestyle
• Family history of diabetes
• Age 40 years and older
• History of gestational DM
• History of delivering infant weighing more than 10 lbs
• African American (33% higher risk for type 2 DM)
Slide 10
Risk Factors (cont.)
• Metabolic syndrome
• Thought to be a precursor to diabetes
• Impaired glucose tolerance, high serum insulin, hypertension, elevated triglycerides,
low HDL cholesterol, altered size and density of LDL cholesterol
TALKING POINTS:
• What is syndrome X?
5
Slide 11
Microvascular Complications
• Retinopathy
• Pathological changes in the retina that are associated with DM
• Nephropathy
• Kidney damage
TALKING POINTS:
• Among people 25 to 74 years of age, DM is the leading cause of blindness.
• What are the two types of diabetic retinopathy?
• Signs and symptoms that suggest impending eye problems are the presence of spots
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 11
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 12
Macrovascular Complications (cont.)
• Accelerated atherosclerotic changes in the person with diabetes
• Associated with coronary artery disease (CAD), cerebral vascular accidents (CVA or
stroke), and peripheral vascular disease (PVD)
TALKING POINTS:
• What vessels are affected by atherosclerosis?
• Individuals with diabetes have a 2- to 4-fold increased risk for heart disease and stroke,
which accounts for 68% of the deaths in people with diabetes.
• Treatment for macrovascular disease is directed toward weight loss, exercise, and
tobacco cessation.
Neuropathic Complications
• Neuropathy: pathologic changes in nerve tissue
TALKING POINTS:
• Almost 30% of individuals older than age 40 with diabetes have impaired sensation in as
least one area of the foot.
• What percentage of people who have had DM for more than 25 years experience
neuropathies?
Slide 14
Hypoglycemic Unawareness
• The usual symptoms of tachycardia, palpitations, tremor, sweating, and nervousness
may be absent
• Patient may suddenly have changes in mental status as the first sign of hypoglycemia
TALKING POINTS:
• What is hypoglycemic unawareness attributed to?
Slide 15
Foot Complications of Diabetes
• May have foot problems associated with neuropathy, inadequate blood supply, or a
combination
• Mechanical irritation
• Thermal injury
• Chemical irritation
TALKING POINTS:
12 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 16
Long-Term Complications: Prevention
• Diabetes Control and Complications Trial (DCCT): intensive treatment of type 1 DM
delayed the onset or slowed the progress of diabetic retinopathy, nephropathy, and
neuropathy
TALKING POINTS:
• Tight control means that the blood glucose is maintained in the normal range with
carefully balanced drugs, diet, and exercise.
• What medications are recommended for patients with increased cardiovascular risks?
Long-Term Complications: Prevention (cont.)
• ADA recommends
4,
6
–
8
Slide 18
Acute Hypoglycemia
• Dangerous drop in blood glucose
• Causes
• Taking too much insulin, not eating enough food or not eating at the right time, an
inconsistent pattern of exercise
• Gastroparesis, renal insufficiency, and certain drugs including aspirin and beta–
adrenergic blockers
TALKING POINTS:
Slide 19
Acute Hypoglycemia (cont.)
• Signs and symptoms
• Adrenergic: shakiness, nervousness, irritability, tachycardia, anxiety,
lightheadedness, hunger, tingling or numbness of the lips or tongue, and diaphoresis
Slide 20
Acute Hypoglycemia (cont.)
• Treatment
• Give patient 15–20 g of quick-acting carbohydrates
• Repeat every 15 to 30 minutes until blood glucose is >70 mg/dL for adults, 80 to 100
mg/dL for older adults and children
TALKING POINTS:
• What are examples of quick-acting carbohydrates?
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 21
Diabetic Ketoacidosis (DKA)
• Life-threatening emergency caused by a relative or absolute deficiency of insulin
• Early signs and symptoms
• Anorexia, headache, and fatigue
• As condition progresses, classic symptoms of polydipsia, polyuria, and polyphagia
develop
• If untreated, patient becomes dehydrated, weak, and lethargic with abdominal pain,
nausea, vomiting, fruity breath, increased respiratory rate, tachycardia, blurred vision,
and hypothermia
TALKING POINTS:
Slide 22
Diabetic Ketoacidosis (DKA) (cont.)
• Late signs
• Air hunger (Kussmaul respirations), coma, and shock
Slide 23
Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
• Patient goes into a coma from extremely high glucose levels (>600 mg/dL)
• There is no evidence of elevated ketones
• Pancreas produces enough insulin to prevent breakdown of fatty acids and formation
TALKING POINTS:
• Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) may be caused by the same
factors that trigger ketoacidosis.
• It also can be brought about by total parenteral nutrition or dialysis.
• Why can intravenous solutions that contain high amounts of glucose cause HHNS?
9
Slide 24
Medical Diagnosis
• One or more of the following criteria on two separate occasions is considered DM
• Polyuria, polydipsia, polyphagia, unexplained weight loss plus random glucose level
≥ 200 mg/dL
14 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 25
Medical Diagnosis (cont.)
• Prediabetes
• Individuals with impaired fasting glucose (IFG) and/or impaired glucose tolerance
(IGT)
• Individuals should receive education on weight reduction and increasing physical
activity
TALKING POINTS:
• What fasting glucose levels indicate IFG? IGT?
• Patient then given a drink (Glucola) containing 75 g of carbohydrates and instructed
samples, blood is drawn at hourly intervals until the test is completed
Medical Diagnosis (cont.)
• Oral glucose tolerance test
• Diet of 150 to 300 g carbohydrate for 3 days before test
TALKING POINTS:
• How can the need for multiple venipunctures be eliminated?
10
Slide 27
Medical Treatment
• Nutritional management
• Medical nutrition therapy (MNT) is an important part of diabetes management; should
be included in diabetes self-management education
TALKING POINTS:
• What are the goals of medical nutrition therapy?
• To maintain weight, a caloric intake of 28 calories/kg of body weight is required.
• To reduce weight, the caloric intake is calculated based on 15 to 20 calories/kg body
weight.
• Patient teaching should include sample menus that include as many favorite foods as
possible.
Medical Treatment (cont.)
• Nutritional management
________________________________________________ Chapter 48Diabetes Mellitus and Hypoglycemia 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 29
Medical Treatment (cont.)
• Recommended calorie distribution for patients who take insulin
• Calorie intake is distributed as mix of carbohydrates, proteins, and fats
• Saturated fats should be < total calories; reduction of trans-fat
• High-protein diets may be associated with an increase in the glomerular filtration
rate; protein sources should come from lower-fat sources
• Carbohydrates should come from whole grain breads, cereals, pasta, beans, brown
rice, fruits, and vegetables
• High-calorie foods with low nutritional value should be limited
Slide 30
Medical Treatment (cont.)
• Exercise
• Effective adjunct for people with diabetes
• Aids in weight loss, improves cardiovascular conditioning, improves insulin
sensitivity, and promotes a sense of well-being
• Exercising muscle uses glucose at 20 times the rate of a muscle at rest and does not
require insulin
TALKING POINTS:
• Exercise is known to improve low-density lipoproteins, serum glucose, blood pressure,
Slide 31
Insulin Therapy
• All patients with type 1 disease need insulin injections; some patients with type 2 disease
may eventually need insulin
• Insulins classified by source and course of action
• Source: human, pork, or beef
• Course of action: rapid-acting, short-acting, intermediate-acting, and long-acting
• All rapid-acting and short-acting insulins are clear
• The other insulins (except Lantus and Levemir) are cloudy
Slide 32
Insulin Therapy (cont.)
• Route
• Oral: insulin cannot be given orally because it is rendered useless in the
gastrointestinal tract
• Subcutaneously: all insulins can be given subcutaneously
• Intravenously: ONLY regular insulin can be given intravenously
16 Chapter 48Diabetes Mellitus and Hypoglycemia _________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 48.1
Slide 33
Insulin Therapy (cont.)
• Concentrations
• U-100 insulin has 100 units/mL
• Most commonly used
• U-500 insulin has 500 units/mL
• Used only in emergencies and for patients who are extremely insulin-resistant
Insulin Therapy (cont.)
• Premixed insulin products
• Contain both Regular and NPH insulin
Slide 35
Insulin Therapy (cont.)
• Dosing schedules
• Conventional therapy
• Typically uses a combination of a short-acting and an intermediate- or long-
acting insulin
• Basal-bolus (intensive therapy)
• To achieve tight control; may require 3 or 4 injections daily, home blood glucose
monitoring
• Continuous subcutaneous insulin infusion
TALKING POINTS:
• Exogenous insulin is administered in an effort to mimic the action of a normal pancreas.
• What is a major problem with conventional therapy?
• The preprandial (before-meal) doses are adjusted for the caloric content of the meal with
intensive therapy.
Slide 36
• The rate of absorption from the abdomen is approximately 50% faster than from the
thighs.
Insulin Therapy (cont.)
• Insulin mixing
• Two types can be mixed in one syringe to avoid two injections
• Insulin injection
• Site rotation helps prevent lipohypertrophy or lipoatrophy
• Absorption rate varies with different body sites
TALKING POINTS:
• What are the steps for mixing two types of insulin in the same syringe?