Summary of information on diabetes. Common early symptoms. Many patients with type 2 diabetes have central obesity, an increase in adipose …
Summary of information on diabetes
Common early symptoms
Many patients with type 2 diabetes have central obesity, an increase in
adipose tissue around the waist In fact, its been shown that central
obesity often precedes and predicts the development of type 2 diabetes
p22
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Risk factors
Genetics p22, being overweight or obese, having a medical history of
gestational diabetes, and belonging to an at-risk ethnic group p23
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Complications
A persistently high blood glucose level is a serious problem As the level
of glucose rises, blood becomes more viscous and flows less readily This
decrease in circulation hampers the bodys ability to fight infection
and heal wounds because the white cells cant get in to do their job
Platelets, needed for normal coagulation, tend to form clumps that can
actually clog up the tiny capillaries, causing a decrease in
microcirculation p22
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Patients with type 2 diabetes
are also at increased risk for serious
complications like heart disease, blindness, neuropathy, and kidney
disease p22
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
Macrovascular complications
Coronary artery disease CAD can lead to acute myocardial infarction MI
p23
Cerebrovascular disease stroke and transient ischemic attack Patients
may exhibit symptoms like hemiparesis, slurred speech, lack of muscle
coordination ataxia, and confusion p23
Peripheral vascular disease PVD Intermittent lameness, cold feet, and
pain p23
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
Microvacular complications
About 20 of patients newly diagnosed with type 2 diabetes have
microvascular complications p25
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Retinopathy is a disease of the eye that causes minihemorrhages, swelling,
and decreased vision Diabetic retinopathy is usually seen within 5
years of the onset of diabetes But theres a catch: Because most patients
with type 2 diabetes arent diagnosed until 5 to 6 years after theyve
actually
developed the disease,
retinopathy may have already occurred at the time of diagnosis Once a
patient is diagnosed with type 2 diabetes, he should be immediately
referred to an ophthalmologist p25
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Nephropathy is a disease of the kidneys characterized by above-normal
amounts of protein in the urine About 20 to 40 of patients with diabetes
will develop it p25
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Neuropathy involves the nerves and affects the patients sense of touch and
various functionsNegative sensory symptoms include numbness, a feeling
of wearing gloves or walking on stilts, loss of balance, and painless
injuries Positive symptoms include burning, pricking pain, electric shock
sensation, tightness, and hypersensitivity to touch
Motor symptoms can cause diminished hand coordination and the inability to
open jars or turn keys Symptoms of proximal weakness include difficulty
going up and down the stairs and rising from a seated or lying position,
falls due to sudden weakness, and trouble raising the arms above shoulder
level
Autonomic symptoms include dry mouth; abnormal sweating; inability
of the pupils to readily adjust to changes in light; photosensitivity;
postural light-headedness or fainting; urinary urgency, incontinence, 27
and dribbling; gastrointestinal problems nighttime diarrhea,
constipation, vomiting; and lost or impaired sexual function
Delayed gastric emptying gastroparesis can also be a problem In this
disorder, the stomach takes too long to empty its contents Symptoms
include abdominal distention, gas, an early feeling of fullness, and nausea
and vomiting p28
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Suggested screening program
3-year intervals beginning at age 45 years, particularly in those with BMI
_25 kg/m2 pS6
Pre-diabetes indicators:
IFG FPG 100 mg/dl 56 mmol/l to125 mg/dl 69 mmol/l
IGT 2-h plasma glucose 140 mg/dl 78 mmol/l to 199 mg/dl 110 mmol/l
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005 pS5
Lab tests
Three tests can be done to diagnose diabetes: the fasting plasma glucose
FPG, the casual plasma glucose concentration CPGC, with casual
meaning
with no regard to the last meal, and the 2-hour postprandial after a
meal glucose test 2hpp In this last test, a patients FPG level is
ascertained after 12 hours of fasting Then he drinks a solution containing
a glucose load equivalent to 75 grams of glucose dissolved in water-
glucola After 2 hours, a blood sample is drawn and his glucose level is
measured again A diabetes diagnosis is confirmed if the FBG is 126 mg/dl
or more; or the CPGC is 200 mg/dl or more with symptoms of urinary
frequency, thirst, and weight loss; or the 2hpp is 200 mg/dl or more
p22
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
A1C test
An A1C test [should be] done every 3 months p33
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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[because] elevated A1C values increase the likelihood of the microvascular
complications of diabetes and perhaps macrovascular complications as well
p2399
Consensus Statement on the Worldwide Standardization of the Hemoglobin A1C
Measurement Diabetes Care, Volume 30, Number 9, September 2007
Since the A1C test reflects mean glycemia over the preceding 2-3
months,
measurement approximately
every 3 months is required pS10
The A1C should be used not only to assess the patients control over the
preceding 2-3 months
but also as a check on the accuracy of the meter or the patients self-
reported results and the adequacy of the SMBG testing schedule pS11
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005 pS5
Test for lipid disorders
In adult patients, test for lipid disorders at least annually and more
often if needed to achieve goals
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005
Test for microalbuminuria
Perform an annual test for the presence of microalbuminuria in type 1
diabetic patients with diabetes duration of ?5 years and in all type 2
diabetic patients, starting at diagnosis and during pregnancy pS19
Table 8-Definitions of abnormalities in albumin excretion
Category Spot collection _g/
mg creatinine
______________
Normal 30
Microalbuminuria 30-299
Macro clinical-
albuminuria
300
______________________________________
Because of variability in urinary albumin excretion, two of three specimens
collected within a 3- to 6-month period should be abnormal before
considering a patient to have crossed one of these diagnostic thresholds
Exercise within 24 h, infection, fever,
CHF, marked hyperglycemia, and marked hypertension may elevate urinary
albumin excretion over baseline values p S18
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005
Tests for high risk patients
ankle-brachial index ABI be assessed in all patients with diabetes over
age 50 If the results are normal, the test should be repeated every 5
years The health care provider should also consider screening the ABI in
patients with diabetes who are younger than 50 and have other risk factors
for PVD like smoking, hypertension, or hyperlipidemia or whove had
diabetes for more than 10 years p23
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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A normal ABI is 091 or more Lower readings indicate reduced blood flow in
the legs caused by narrowing of the arteries Moderate
obstruction is
diagnosed if the ABI is 04 to 069; a result less than 04 indicates
severe obstruction p23
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
In some patients with diabetes, the blood vessels are difficult to compress
due to changes in the vascular endothelium caused by the disease These
patients may have a normal or an elevated ABI over 130, but
they may still have symptoms of PVD If the ABI doesnt make sense based on
the patients symptoms, the health care provider may measure toe pressure
instead This is often a more reliable assessment of lower extremity blood
flow in patients with diabetes p23
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Any patient with type 2 diabetes should have his feet examined at every
office visit Encourage him to
check his feet daily for any signs of redness, swelling, or discoloration
Advise him to avoid going barefoot because of the increased risk for an
injury that may go unnoticed and progress to a serious wound clinicians
inspect their patients shoes for blood or other discharge, abnormal wear
patterns, foreign objects,
proper fit,
appropriate material, and protective quality p28
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Care for diabetics patients
Type 2 diabetes requires lifelong medical care, monitoring, and patient
education to prevent acute complications and reduce the risk of long-term
complications It isnt just about glycemic control; there are plenty of
other interventions that have been shown to improve diabetes outcomes
p20
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
a management plan include:
a balanced diet
regular exercise
medication
serum glucose monitoring p29
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
lifestyle modification should be the first choice to prevent or delay
diabetes Modest weight loss 5-
10 of body weight and modest physical activity 30 min daily are the
recommended goals pS5
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005
Ideal blood glucose values for patients
The ADA recommends the following:
a preprandial serum glucose level of
90 mg/dl to 130 mg/dl
a postprandial serum glucose level of less than 180 mg/dl
an A1C of less than 7 p29
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
Blood pressure control
The recommended blood pressure for patients with diabetes is less than
130/80 mm Hg p30
Blood pressure should be measured at every routine diabetes visit Patients
found to have systolic blood pressure ?130 mmHg or diastolic blood pressure
?80 mmHg should have blood pressure confirmed on a separate day pS15
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
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Diet
ask him what he usually eats in a day Then you can suggest appropriate
modifications to reduce fat, salt, and sugar
Advise the patient to consume a similar amount of carbohydrates at each
meal the patients medication
works on a fairly consistent glucose response from the food
Provide the patient with sample menus for breakfast, lunch, and dinner and
include the carbohydrate counts,
usually in grams
Encourage patients to read the labels of prepackaged foods to find the
carbohydrate count p29
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing
made
Incredibly Easy July/August 2005
Exercise
Strenuous activities like weight lifting and jogging should be avoided if
he has retinopathy or severe neuropathy
Remind your patient that exercise lowers his blood glucose level, so he
should check it before and after exercise to see how its affected by his
workout Advise him to keep a quick-acting carbohydrate, like commercially
prepared glucose tablets, handy in the event of a hypoglycemic event
modest physical activity 30 minutes most days of the week are the
recommended goals p30
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
Patients own blood test and diet records
Ask the patient to keep a written record of his blood glucose levels and
bring the information with him to subsequent office visits Its also a
good idea to have the patient record his diet and exercise in a daily
journal pp33-34
Moshang, J 2005 Type 2 diabetics: Growing by leaps Nursing made
Incredibly Easy July/August 2005
Eye care
Patients with type 2 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist or optometrist shortly
after the diagnosis of diabetes
Subsequent
examinations for type 1 and type 2 diabetic patients should be
repeated annually by an ophthalmologist or optometrist who is knowledgeable
and experienced in diagnosing the presence of diabetic retinopathy and is
aware of its management pS20
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005
Standard eye check
fundus photography comparing the fundus pathology with that seen on
stereoscopic viewing of seven standard photographs for grading retinopathy
or through fluorescein angiographic diagnosis p2302
Telemedicine for eyes
Aravind Diabetic Retinopathy Screening 30
Eye Treatment
Half had focal laser 536, 392 had panretinal photocoagulation
p2305
Perumalsamy, N, Prasad, N M, Sathya, S and Ramasamy, K 2007
Software for Reading and Grading Daibetic Retinopathy Diabetes Care,
Volume 30, Number 9, September 2007
Laser therapy can reduce the risk of vision loss in patients with HRCs
pS20
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005
Foot care
The risk of ulcers or amputations is increased in people who have had
diabetes 10 years, are
male, have poor glucose control, or have
cardiovascular, retinal, or renal complications The following
foot-related risk conditions are associated with an increased risk of
amputation:
Peripheral neuropathy with loss of protective sensation
Altered biomechanics in the presence of neuropathy
Evidence of increased pressure erythema, hemorrhage under a callus
Bony deformity
Peripheral vascular disease decreased or absent pedal pulses
A history of ulcers or amputation
Severe nail pathology pS20
Perform a comprehensive foot examination annually on patients with diabetes
to identify risk factors predictive of ulcers and amputations Perform a
visual inspection of patients feet at each routine visit pS21
Choices of foot exam
Semmes-Weinstein monofilament, tuning fork, palpation and visual
examination pS21
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005
Immunization
Annually provide an influenza vaccine to all diabetic patients 6 months of
age or older
Provide at least one lifetime pneumococcal vaccine for adults with
diabetes A one-time revaccination is recommended for individuals 64 years
of age
previously immunized when they were65 years of age if the vaccine
was administered5 years ago pS14
American Diabetes Association 2004 Standards of Medical Care in
Diabetes Diabetes Care, Volume 28, Supplement 1, January 2005
Source:nhrid.org
