Diabetes is a chronic disorder characterized by either an absolute or relative absence of insulin. Insulin is secreted primarily by the beta cells located in the anterior head, body, and tail of the pancreas. Type 1 and type 2 are the primary categories of diabetes, but other types do exist (gestational diabetes, impaired glucose tolerance, and diabetes related to other conditions). Early detection and treatment of pre-diabetes and diabetes are essential to prevent the serious complications associated with this disease. The focus of this discussion is type 1 and type 2 diabetes.

Type 1 diabetes represents an absolute lack of insulin caused by a decrease in beta cell mass. It affects about 10% of the diabetic population and usually occurs before the age of 30. It is typically detected by an abrupt onset of symptoms of hyperglycemia. The affected patient is often prone to ketoacidosis, which occurs when accumulation of ketones (byproducts of fat metabolism) leads to acidosis, causing diuresis, dehydration, loss of electrolytes, and eventually renal failure, coma, and death.

Type 2 diabetes is related to insulin resistance and a defect in insulin secretion. Sustained hyperglycemia is diagnostic of type 2 diabetes and occurs over a long period of time. Symptoms usually occur after the age of 30 but can occur at any age. Obesity and a sedentary lifestyle are primary factors of occurrence. Type 2 diabetes usually is not prone to ketoacidosis because some insulin is still produced. Treatment is centered on diet, exercise, weight loss, oral medications, and/or insulin as indicated, with careful monitoring of blood glucose levels by the patient and physician.

Patient self-monitoring involves glucose testing four times per day for type 1 diabetes and as indicated for glucose control in type 2 diabetes. Glycosylated hemoglobin (HbA1c) levels are used to determine long-term (about 3 months) glucose control. HbA1c should be maintained at < 7%. Monitoring is aimed at preventing chronic complications, including eye disorders, kidney disease, peripheral neuropathies, and cardiovascular disease.

Treatment protocols involve a combination of diet, exercise, and medications to maintain blood glucose levels as close to normal as possible. Nutrition is no longer based on American Diabetes Association diets but is individualized to patient need and associated with exercise and lifestyle. When diet and exercise do not provide adequate control of blood glucose, medications may be added to the treatment plan. Medications can be oral agents, insulin, or a combination of both for type 2 diabetes. Type 1 diabetes will always require insulin.

For further information on diabetes, review Chapter 22 in the Core Curriculum for Medical-Surgical Nursing (3rd edition), then answer the following questions.

1. The nurse is teaching a patient with a new diagnosis of diabetes mellitus about disease management. Among the "survival skills" that the nurse should identify is:

a. Weight loss.

b. Eliminating sugar from the diet.

c. Self-monitoring of blood glucose.

d. Limited physical activity.

2. Which of the following is characteristic of type 2 diabetes?

a. Absolute lack of circulating insulin

b. Decreased mobilization of glucose by the liver

c. Resistance to insulin by cell receptors

d. Sustained hyperglycemia in both fasting and postprandial blood glucose levels

3. Which of the following is used to measure chronic glucose control?

a. Microalbuminuria

b. HbA1c

c. Fasting plasma glucose

d. Serum ketones

4. To decrease the risk for developing diabetic neuropathy, the nurse will encourage the patient to:

a. Drink 8 to 10 glasses of water daily.

b. Eliminate alcohol.

c. Decrease consumption of red meat.

d. Stop smoking.

1. c--Self-monitoring of blood glucose is the foundation of successful disease management for the patient with diabetes mellitus.

2. d--Insulin resistance is a cause of sustained hyperglycemia in fasting and postprandial blood glucose levels.

3. b--HbA1c provides a picture of glucose control over a period of approximately 3 months.

4. d--Risk factors for the development of diabetic neuropathies include hypertension, smoking, and chronic hyperglycemia.