Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications.

1. MR.JAGDISH SAMBAD
M.SC. NURSING
IKDRC COLLEGE OF NURSING

2. INTRODUCTION
DIABETES was described as the passing of large
amounts of sweet urine in BC 1500. The name
‘Diabetes’ (to pass through) was given in AD 200 by a
Greek physician Artens, later ‘Mellitus’ (sweetened)
was added.
In 1921, insulin was discovered by Dr’s Banting and
Best, before which diabetes patients used to die of
ketoacidosis oral hypoglycemic agents came into use
in 1950.
As per experts today, we have about 30million people
suffering from diabetes in India .This number is
expected to increase to more than 50million by 2025.

3. DEFINITION :
• Diabetes Mellitus : is a chronic disease caused by
inherited and/or acquired deficiency in production of
insulin by the pancreas or by ineffectiveness of the insulin
produced. Such deficiency results in increased
concentrations of glucose in blood which in turn leads to
damage of many of the body's system, especially the
blood vessel and nerves.
• Insulin : is a hormone produced by beta cells of the islets
of Langerhans in the pancreas gland. Insulin helps the
metabolism of glucose for utilisation in the body and stores
the excess glucose in the liver and muscle as glycogen.
Insulin also helps in depositing the free fatty acids in
the tissues.

4. EPIDEMIOLOGY
• It is uncommon in infants, increase in frequency
until adolescence and then drops sharply. It has two
definite peaks, one at about 5years and the other
about 10-12years.
• Seasonal variation has also been noted with children
being diagnosed more often in winter than summer
months.
• Diabetes Mellitus is found most frequently in
persons over 40years of age who are obese and who
have a family history of diabetes.

5. RISK FACTORS :
People with any of the following factors have
greater chances of developing chronic diabetes –
Obesity
Hypertension or any chronic illness
Family history of diabetes
Continuous stress.

6. Etiologic classification of Diabetes mellitus.
• Types – 1 Diabetes (B-cell destruction)
a.Immune mediated
b.Idiopathic
Types - 2 Non Insulin Dependent Diabetes mellitus.
- After age of 40years.
-May have a family history of Diabetes.
- Most of obese and Glucose level improves
on weight loss.
Types – Gestational Diabetes mellitus
- Applies only to women
- Appear during pregnancy & disappears after
pregnancy is terminated.

7. Secondary Diabetes Mellitus
• Genetic defects of B-cell function
• Genetic defects in insulin action
• Disease of the exocine pancreas
• Hormonal disorders like thyrotoxicosis, Cushing's
syndromes, acromegally, cystic fibrosis.
• Congenital Rubella syndrome, CMV,
• Surgery
• Down’s syndrome
• Drug or chemical induced.(pentamidine steroids,
dilantin, thiazides, diazoxide)

8. Etopathogenesis
• 95% of childhood diabetes mellitus are idiopathic
with absolute deficiency of insulin due to hereditary
inborn error of metabolism.

9. Etipathogenesis
Etiology of type-1 are considered
Genetic Environmental Autoimmune
factors reaction
Due to autoimmune reaction
Inflammation of the beta cells of pancreas
Inflammatory process stimulate beta cells
Produced slightly abnormal class-II HLAs
(Human leukocytes Antigens)
Lymphocytes recognise these antigen as nonself & destroy them
Releasing more B cell proteins
Can make additional HLAs
Stimulation an ongoing immune response
That eventually destroys all B cells which secrete insulin.

10. Clinical manifestations
childhood diabetes is usually rapid in onset and may present
with diabetic coma. Obesity place no role in childhood
diabetes mellitus.
1. Polyuria – increased urination
2. Polydipsia – increased thirst
3. Polyphagia – increased appetite
4. Nocturia
5. Enuresis
6. Weight loss
7. Sleepiness
8. General weakness, tiredness & bodily pain.

11. 9. Fainting attack due to hypoglycemia.
10. Pain abdomen
11. Nausea
12. Vomiting
13. Irritability
14. Valvovaginitis in girls
15. Poor wound healing.
16. Visual disturbances.
17. Skin infection
18. Dry skin.

12. Diagnostic finding
a) History of classical triad symptoms.
b) Physical examination
- Blood pressure
- Bony mass index (height and weight)
- Fundoscopic examination.
- Foot examination (lesions, signs of infection)
- Skin examination ( lesions and insulin injection)
- Neurological examination
- Oral examination.
c) History of illness

13. d) Laboratory investigations
Determination In client Conventional units
1. R.B.S. Level 200 mg/dl or
more
65-140mg/dl
2. F.B.S. 126 mg./dl or more 60-110 mg/dl
3. P.P.B.S. More than normal 65-140 mg/dl
4.Urine glucose Positive Negative.
5. Glucose
tolerance (oral)
No longer
recommended
1.Normal fasting between-
60-110 mg/dl
2. No sugar in urine
3. Upper limits of normal
Fasting – 125
1 hr- 190,2 hr-140,3 hr-125

14. Diabetes management
Diabetes mellitus is a complex disease with multiorgan
involvement.
Management of Diabetes mellitus in children involves
combination of :
i. Insulin therapy
ii. Dietary management
iii. Physical exercise
iv. Prevention of complication
v. Promotion of growth
vi. Emotional social development

15. Insulin therapy
Principles of therapy and monitoring :
a. Elimination of clinical features of uncontrolled diabetes.
b. Prevention of DKA
c. Avoidance of hypoglycemia
d. Maintenance of normal growth and maturation
e. Early detection of associated disease
f. Prevention of emotional disorders
g. Prevention of chronic vascular complications of diabetes
Insulin is formed from a substance called proinsulin.
The increased blood glucose level stimulation the proinsulin into
insulin and connecting peptide and enters the blood stream.
Insulin is produced in two phases.
First phase- immediately after the glucose level stimulates. This
insulin is already produced in he pancreas and stored.Pancreas can
store 2000 of insulin a time.
Second Phase – produced as per further requirements.

16. Functions of Insulin
1. Certain amount of insulin readily circulates in the
blood which is called basal insulin.
2. Insulin enhances fat storage and prevent fat
mobilisation for energy.
3. Insulin stimulates glucose transported to enable
entry of glucose transporters to enable entry of
glucose into cell for utilization as energy source.
4. Insulin promotes glucose storage in liver and
muscle as glycogen.

17. Types of insulin
Insulin can be categorized under the following.
a. Species/source of insulin.
b. Duration of action of insulin.
c. Purity of insulin.
d. Concentration of insulin.
e. Trade names of insulin.
Source and purity:-
i. Beef insulin.
ii. Human biosynthetic
iii. Pork insulin.
iv. Beef-pork combination of insulin.

18. Duration of action:-
Insulin are categorized as per duration of action as
under.
a. Short acting (Rapid acting/Regular/Plain/Solule)
b. Intermediate acting insulin.
c. Long acting insulin.
d. Biphasic insulin.
CONCENTRATION:-
The insulin available in India are 401U 1 ml and
1001U in insulins in 1 ml.
Injection technique.

23. Exercise and physical activity.
Exercise effects in diabetes was recognized in 1920s.
Exercise is a good too to control this, if carried out regularly
and achieve physical fitness.
Exercise is extremely important in managing diabetes
because of its effects on lowering blood glucose and
reducing cardiovascular risk factors.
- Exercise lowers the blood glucose level by increasing the
uptake of glucose by body muscles and improving, insulin
utilization.
- Resistance training, such as weight lifting, can increase lean
muscle mass. Thereby increasing the resting metabolic rate.
- Exercise also alters blood lipid levels, increasing levels of
high-density lipoproteins and decrease total cholesterol and
tryglyceride levels.

24. Exercise precautions
• Use proper footwear and if appropriate other protective equipment.
• Avoid exercise in extreme heat or cold.
• Inspect feet daily after exercise.
• Avoid exercise during periods of poor metabolic control.
• Clients who have blood glucose level exceeding 250 mg/dt and who
have ketones in the urine should not begin exercising until urine tests
negative for ketones and blood glucose levels increases the secretion
of glucogen,growth hormone and catecholamine.
• The client who requires insulin should taught to eat a 15gm
carbohydrate with protein before engaging in moderate exercise, to
prevent unexpected hypoglycemia.
• Exercise should include walking, jogging, aerobic exercises and
games.

25. Diet Therapy
Daily dietary planning for diabetic children is important for prevention
of acute or long term complications and promotion of growth and
development.
Dietary regulation means a life style changes for the patient. Diet should
be recommended depending upon the blood sugar level, metabolic
status, standard of living and requirements for growth and
development.
While planning the diet:-
1. Consider the type of diabetes.
2. Consider the present dietary habit.
3. Consider activity of the patient.
4. Consider time rigidity and flexibility.
5. Calculate the requirements of calories as per weight, age and
activity.
6. Consider any other chronic disease involvement
7. Consider tradition and culture as well as family back ground.

26. Calories requirements
i.e. 30 kcal/kg/day + 510 cal/kg/day.
Diet calorie is calculated for the ideal body weight.
- For quick calculation of ideal body weight.
- Height in cm minus 100 per men.
- Height in cm minus 105 for women.
- Caloric requirement for children should relate to growth.
- The requirement in high per kg. From 0-12 months and gradually
comes down from 1 year to 10 years.
Food,Medication and Timing:-
1. The food taken by diabetes patients should preferably be at the same
time everyday.
2. Patient on insulin injection should balanced food and medicine.
3. They should be taught to adjust the timing of insulin in case of
social gathering and parties.
4. The food exchanges for same calories should be known to all clients.

27. COMPLICATIONS : Complications are presented as
acute, sub acute &chronic conditions
a. Acute complications : -diabetic coma
-Hypoglycemia
-DKA
-Infections
b. Sub acute complications:- Growth failure
- poor school performance
- poor psychological deve.
-impaired neurological deve.
c. Chronic complications:- macro vascular
- Retinopathy
- Neuropathy
-Nephropathy
-Hepatomegaly

28. d. Chronic infections :-boils
-stypes
-abscesses
-fungal infections
-Tuberculosis
-Hypertension
-Artherosclerosis
-CCF
-Blindness may also develop
in the children having diabetes mellitus.

29. NURSING MANAGEMENT
• NURSING DIAGNOSIS:
1. Fear and anxiety related to long term illness
2. Imbalanced nutrition related to imbalance of insulin, food
& physical activity.
3. Risk for injury related to hypoglycemia
4. Risk for injury related to insulin deficiency.
5. Risk for infection related to hyperglycemic state
6. Risk for fluid volume deficit related to polyuria &
dehydration.
7. Potential self care deficit related to physical impairments
or social factors
8. Knowledge deficit related to care of a child with newly
diagnosed diabetes mellitus.