Diabetes mellitus

AIMS & OBJECTIVES

To improve the quality and duration of life of people with diabetes

By the maintenance of near normal blood glucose levels
By the reduction of risk factors such as smoking, obesity, hyperlipidaemia and hypertension.
By the early detection and treatment of complications
By the early diagnosis of diabetes
To educate and empower the patient to achieve both psychological as well as physical well being
To educate members of the Primary Health Care Team (PHCT) caring for patients with diabetes and to evaluate its effectiveness.

Staff Requirements and responsibilities
Risk Factors Associated with Diabetes
Recommended Lifestyle
Education to be covered
Metabolic targets
Diabetic annual review: nurse
3 monthly and 6 monthly checks: nurse
Newly diagnosed patients (Type 2)

Staff Requirements and responsibilities

Practice Nurses
- to have post basic training in diabetes care - ideally ENB 928 or Diploma in diabetes care
- will undertake clinic annual reviews and 3 & 6 monthly checks.
- the education and monitoring of newly diagnosed patients
- P.N.s with specialist training may advise on dose levels of insulin/therapy if they feel competent to do so
- Sister Smithson - the organisation of diabetes care within the surgery and for domicillary care, liaising with all other professionals concerned, D.N.s, optician, dietician, chiropodist, G.P.s.
G.P.s
- to have responsibility for individual patients who are registered with them.
- will undertake the review of patients following their clinic appointment, will make alterations to therapy as appropriate, refer on as necessary to secondary care.

Risk Factors Associated with Diabetes

Cardiovascular - Smoking
Hyperlipidaemia
Hypertension
Nephropathy - micro- albuminuria, albuminuria
raised creatinine levels
Neuropathy - reduced sensation, vibration
Peripheral vascular disease - reduced peripheral pulses & circulation
Complications associated with Diabetes
Visual Impairment - retinopathy
Ischaemic Heart Disease - angina, myocardial infarct, stroke
Renal Failure
Amputation

Recommended Lifestyle

Normal weight for height (BMI near to 25.0)
Diet - healthy eating. Half dietary intake should consist of carbohydrates (preferably complex); reduce sugary foods; reduce fats (particularly saturated poly unsaturated fats; reduce salt; alcohol in moderation. Special ‘Diabetic foods’ are not recommended.fat) - replace saturated fats with mono or
Exercise - at least 3 half an hour walks per week, or a level of exercise that is appropriate.
Smoking - STOP

Education to be covered

This should not be attempted in one visit - small amounts at a time backed up with literature. Enter into notes all that has been covered.

Remember

A pot filling, didactic approach does not work.
What does the patient know, what are their fears, what do they need to know, what is their level of understanding.
Try to be empathic, sit back and allow the patient to ask questions.

An adult needs to know:

Why they need to know it - the reason behind, its relevance to diabetes.
Many need to feel in control of decisions and their lives and not to be told what to do. They tend to resist others imposing their will upon them.
Their past experiences and health beliefs will influence their actions
They have to be ready to learn, and not still ‘in shock’ from the diagnosis
It needs to be relevant to them and the lives that they lead
They need to know what they will gain from complying

Areas to be Covered

Driving - it is a legal requirement that all people with diabetes inform their insurance company, if they fail to do so they may not be covered if they are involved in an accident, even if they are the innocent party. If on tablets or insulin they need to inform DVLA. If on sulphonylureas (e.g. gliclazide) or insulin need to be aware of the danger from hypos. Don’t miss meals. Test blood. Carry snacks. Stop driving immediately if unwell.
Explanation of Diabetes - aetiology- cause and relationship between food, treatment and control. Effects of exercise & illness. Important to address the psychological aspects and patients concerns. Ascertain patient’s knowledge base and answer questions rather than ‘pot filling’ with advice.
- Type 1 - insulin deficient Treatment and effect of pills/insulin - most
- Type 2 to start on diet only.
Diet, Exercise and Alcohol - all patients to be referred to dietician.
DAMES = Diet, Acarbose, Metformin, Exercise, Suphonylureas
- if obese - 6 months trial of diet
- on-obese and raised blood glucose and/or symptomatic - ? drug therapy
- If to start oral hypoglycaemics - choose suitable therapy:
  Diet only trial for 6 months. If BMI>30, then metformin (take after food) (<70yrs) or acarbose (>70yrs), otherwise gliclazide (take 30min before food).
- discuss side effects - Acarbose - (take with food) indigestion, flatulence
- Metformin - (take after food) gastric disturbance, metallic taste, diarrhoea, bloating, nausea, loss of appetite.
- Suphonylureas - (take 30 mins before food) Hypos, weight gain.
Self Monitoring -
Type 2 usually only need to test their urine - 2 hours post prandial. Explain relationship between glycosuria and food intake and exercise levels. Use as education tool as well as for monitoring control.
Type 1 to do BMs. Usually started off in hospital and most under secondary care or shared care. Test before meals and bed. Best to do blood series (4 times throughout the day), then rest for a few days unless needing to do extra for symptomatic monitoring e.g. extra exercise, different food intake, alcohol, unwell, driving.
Reasons for good control - well being (feel better, less tired), prevention of complications.
Illness - do not stop treatment. Type 1 frequent monitoring, check ketones, ? extra insulin, maintain carbohydrate intake (in liquid form if necessary), maintain fluids. If necessary - Contact GP SOS.
Identification - Bracelet or card
BDA - encourage joining the British Diabetic Association (give application form).
Eyes - Importance of annual check up with opticians. Will be given a form to take to opticians at every annual check up.
If newly diagnosed - do not get new glasses until diabetes is controlled (6 months) or could waste patient’s money!
Note rapid lowering of blood glucose can damage the retina.
Foot Care - Young and capable, without problems - can look after their own feet - after receiving instructions on foot care, dangers, breaking in new shoes, and to see nurse if any problems. Others - refer to chiropodist (and give hygiene instructions etc. with reasons WHY)
Free prescriptions - if on treatment involving diabetic drugs or insulin, eligible for free scripts.

Metabolic targets

Blood Glucose between 4 - 8 (tight control - discuss extra risks of hypos and driving)
Blood Glucose between 4 - 10 (acceptable control particularly in older patients)
HbA1c 7.4 or less (acceptable control) Note this reference range is for acceptable control not good!
Cholesterol < 5.2
B.P. < 140 systolic; 90 diastolic
BMI 25
Creatinine in normal reference range
Urine - no protein present
Urine - if patient has normal renal threshold, then blood glucose will be greater than 10 mmol if glucose is present in urine. Therefore in normal circumstances there should be no glycosuria - however, note high or low renal thresholds: urine testing is for education and as a guide only.
Improved diabetic control can reduce complications in both Type 1 diabetes (DCCT 1993) and Type 2 diabetes (Guillausseau 1998)
All patients with diabetes under PHCT care will be invited to attend an annual review, the target for achievement is 100%.
All patients with > 7.4 HbA1c or with risk factors or complications and all newly diagnosed patients to have 3 monthly checks.
All patients with HbA1c >6.8 to have 6 monthly checks
All patients with HbA1c 6.8 or less may be considered for annual review if the results have been stable for more than a year, the patient knows to self refer if home monitoring shows glycosuria or they feel tired, unwell or concerned.

Diabetic annual review: nurse

Discuss well being and home monitoring results
Patient’s needs and concerns
Revise and update education
Improve control
Prevent complications by targeting risk factors e.g. smoking, lipids etc.
Address any other areas of concern or need (refer on if necessary).
Measurements, Examinations & Tests
Weight
Urine - glucose
Protein (if present check MSU to exclude UTI, ? for 24 hour protein)
Type 1 or Type 2 < 60 micro albuminuria to lab (EMU)
B.P.
Habits - ? Smoking ? alcohol intake
Feet - test for pulses (quality and quantity); vibration and sensation; condition; pain.
Eyes - give form for patient to take to optician for fundoscopy
Compliance - correct tablet/insulin regime (Injection sites)
Diet - relate to home monitoring results
Exercise - encourage within capabilities.
Blood Tests HbA1c; U&Es; Cholesterol; (LFTs if on Metformin or Acarbose)
TFT at 3 yearly intervals. (others in felt necessary ? symptoms e.g. FBC)
Symptoms - angina, claudication, breathlessness, hypos & side effects of drugs etc.
Educate & Empower, Targets patient would like to achieve, changes in treatment and why - possible side effects and implications (if male- don’t forget potential problems such as impotence).
Record all findings and points covered in notes and patient’s ‘Care Card’.
Ask to make appointment with GP in 2 weeks time for blood results
Update computer recall markers

3 monthly and 6 monthly checks: nurse

Well being and home monitoring results (same objectives etc., as for annual review)
HbA1c; B.P.; Weight; compliance.
Address patients needs and concerns
Compliance
Educate
Complete records
Update Care Card and computer recall markers
To make appointment in 2 weeks time with GP (or specialist nurse if well controlled) for results

General practitioner

Discuss with patients - their concerns and well being
Check nurse’s findings and if appropriate re-examine
Discuss patient’s targets in relation to laboratory results
Alter therapy if necessary
Target risk factors - add hypotensives, lipid lowering drugs, aspirin etc.
Treat complications
Address any other concerns
Educate
Discuss future targets
Refer to secondary care if necessary
Update notes and alter recall markers if felt necessary
Update patient’s care card with blood results

Newly diagnosed patients (Type 2)

Baseline measurements - Glucose (fasting), Cholesterol (fasting), U&Es, LFT, TFT, FBC. Blood Pressure. Weight. Smoking Status
Driving insurance
Diet (what do they normally eat?) give guidelines - REFER ALL patients to dietician.
Give ‘balance for beginners’ (on loan only!)
Listen to fears & concerns - mainly answer questions and reassure
? home monitoring - assess if able to take in any more first.
Give written instructions for all these points
Put in ‘diagnostic marker’ and 3 month and annual recall markers on computer
update notes
Make appointment for 2 weeks time
2 Weeks Later
Answer questions from reading balance for beginners
Patients concerns
Educate through answering questions - try to cover ‘cause of diabetes’, ‘effects’, ‘control - principles and practice’.
Home monitoring - Urine testing 2 hours after meals (record food eaten alongside)
Diet ‘the role of fats and sugars’
BM and relate to diagnosis, cause and target needed
Smoking - effects, especially in relation to diabetes
BP
Weight - effect of obesity on diabetes ‘insulin resistance’ See Figure 1
Exercise - effect on diabetes and ‘insulin resistance’
Target the patient would like to reach
Update notes
Take into account the individuals need to know, and ability to learn - this is only a guideline and has to be tailored to the individual.
Make appointment for 2 weeks time
1 month after diagnosis
Patient’s well being and concerns
Home monitoring results
Relate to diet and exercise - try to illustrate cause and effects from the results
Answer questions and use to educate - go over previous information
Examine feet, pulses and vibration, sensation - give reasons why and the care necessary. Refer to chiropodist if necessary.
Weight
Recheck BP if it was previously raised
Do BM and relate this result to improved lifestyle and compliance (recap on cause and effect)
Symptoms (if non obese and symptomatic, may consider oral therapy)
Discuss targets, and if confident leave till 3 month recall, with ‘open invitation’ to return. Trial of diet for all other newly diagnosed patients, particularly if obese.

References

DCCT 1993 Diabetes control and complications trial New England Journal of Medicine Vol 329 No 14 p 972-986
Guillausseau, P et al 1998 Glycaemic control and the development of retinopathy in Type 2 diabetes mellitus: a longitudinal study Diabetic Medicine Vol 15 No 2 p 151-155

Bradley Cheek 1999