DIABETES
WORKBOOK
By
FIFE DIABETES
SERVICE
Version 2012
Introduction
Current statistics indicate 1.9 million people in the UK have diabetes; 90% of
those have type 2 diabetes. A further 0.5 million people have undiagnosed
diabetes. The Centre for Disease Control and Prevention predicts an ‘epidemic’
as estimations of population growth of people with diabetes indicate these figures
will double by 2025 (National Institute of Clinical Excellence (NICE 2009). ‘In
2009 there were around 228,000 people registered as having diabetes in
Scotland, an increase of 3.6% from the preceding year’ NHS Scotland 2009
The Diabetes Control and Complications Trail (DCCT) 1993 and United Kingdom
Prospective Diabetes Study (UKPDS) (1998), demonstrated the benefits
associated to good glycaemic control to reduce the risk of developing micro and
macro vascular complications. These complications can impact significantly on
the quality of life. Thus, national and international diabetes management
standards associated to glycaemic control underpin the findings of these major
studies.
The aim of delivering effective diabetes management is to educate and encourage
patients to self manage their diabetes and minimise potential diabetes
complications.
Aims
This workbook is intended to support your learning of diabetes management and
the application to all areas of your nursing practice. The Fife Diabetes Handbook
(2008) was used as a model for the development of this workbook. The handbook
was based on the Scottish Intercollegiate Guidelines Network (SIGN 2001)
guidelines. The SIGN guidelines have been updated in March 2010 and in the
SIGN document 116 – ‘Management of diabetes’
The aims and objectives for this workbook are as follows:1)
2)
3)
4)
5)
To enhance your understanding of ongoing diabetes management for
patients with diabetes mellilitis.
To enhance your understanding of diabetes management for the acutely ill
patient.
To provide a basic understanding of diabetes medication.
To enhance your understanding of the implications of life with diabetes.
To be able to fulfil health promotional needs for patients with diabetes.
Type 2 Diabetes
Management
Lifestyle
Education
Oral Antidiabetic
medication.
P.12-16
Type 1 Diabetes
Management
Injection
Technique
Insulin Therapy
Education P.6-11
Research
Developmen
t
Health
Promotion
P. 17
What is
Diabetes?
How to
Diagnose
Diabetes?
What is
HbA1c? P4
Contacts
Community
Teams
Further
Information
P.22-24
Ward
Relevant
Informati
on. P.1920
Acute and
Chronic
Complications.
P.18
Members of
the Multidisciplinary
Team P.21
WHAT IS DIABETES?
Diabetes mellitus is a condition in which there is a raised blood glucose
concentration. Diabetes is a result of an absolute or relative lack of the hormone
insulin caused by either the pancreas not producing insulin or insufficient insulin or
insulin action for an individual’s needs. This is also known as insulin resistance.
Can you describe the physiological differences between a person with diabetes
and a person without diabetes?
What are the symptoms of diabetes mellitus type 1?
What are the symptoms of diabetes mellitus type2?
There are two main classifications of diabetes mellitus, Type 1 and Type 2.
How would you define these classifications of diabetes?
How are these diabetes’ classifications diagnosed, using the World Health
Organisation guidelines?
Can you list other classifications of diabetes mellitus?
TYPE 1 DIABETES MELLUTIS
When an individual is diagnosed with type 1 diabetes, the initial education will be
to optimise their safety with insulin therapy. This education begins with insulin
administration, blood glucose monitoring and hypoglycaemic management.
Insulin administration:Please discuss the following and their relevance to diabetes
Subcutaneous injections
Injection sites
Lipohypertrophy
Types of needles and insulin administration devices
Sharps disposal
Home blood glucose monitoring (HBGM)
Please discuss the following and their relevance to diabetes. (Liaise with several
glucometer representatives)
How do you assess a patient’s blood glucose control, and why?
Can you list some differences between glucometers?
Another method of assessing an individual’s diabetes control is via a venous
sample called Glycated Haemoglobin (HbA1c). This sample demonstrates a 2-3
month average of their diabetes control. It was also the test that was used as the
basis for the DCCT and UKPDS research. The table below lists the target goals.
Good
DCCT HbA1c
IFCC –
HbA1c
Average
Blood
Glucose
Urine
Test
Good
Average
Poor
Poor
Very Poor
6
7
8
9
10
11
42
53
64
75
86
97
7
8
10
12
14
16
neg
0.25%
0.50%
1%
2%
>2%
At the time of writing the NICE guidelines recommend a target HbA1c of 6.5% and
there is no specific SIGN target due to the lack of supporting evidence but
generally local targets range from 6.5-7.5%. GPs have similar targets. The
exceptions to these targets are individuals who are at high risk; such as the
elderly.
INSULINS – Insulin therapy is essential treatment for the management of
patients with type 1 diabetes. Insulin therapy is also a common treatment
for the management of type 2 diabetes patients. This does not alter a
patient’s diagnosis and has cause confusion with historical diabetes
classifications. Please fill in the boxes
Rapid-acting Analogue
Brand Name
Generic
Name
Novorapid
Humalog
Apidra
Onset
Short-acting Insulins/Neutral Insulin
Brand Name
Generic
Onset
Name
Actrapid
Humlin S
Peak
Duration
Peak
Duration
Peak
Duration
Peak
Duration
(Hypurin Bovine Neutral
Hypurin Porcine Neutral
Insuman Rapid) - less
common insulins
Medium-acting and Long-acting Insulins
Brand Name
Generic
Onset
Name
Insulatard
Humulin I
(Hypurin Bovine Isophane
Hypurin Bovine Lente
Hypurin Bovine PZI
Hypurin Porcine Isophane
Insuman Basal) Less
common insulins
Mixed Insulins
Brand Name
Generic
Name
Mixtard 30
Humulin M3
Insuman comb
25
Onset
(Hypurin Porcine 30/70
Mix
Insuman Comb 15
Insuman Comb 50) –
Less common insulins
Analogue Mixture
Brand Name
Generic
Name
Humalog mix
25
Humalog mix
50
NovoMix 30
Long-acting Analogue
Brand Name
Generic
Name
Lantus
Levemir
Onset
Peak
Duration
Onset
Peak
Duration
Another developing area of type 1 diabetes is Continuous Subcutaneous Insulin
Infusion (CSII) or commonly referred to as insulin pumps. This is a device that
administers a continuous infusion of short-acting insulin that can be instantly
adjusted to the patient’s lifestyle and dietary intake. The purpose of this pump is
to achieve optimal diabetes control and offers flexibility to the patient. Each Trust
operates their own criteria process based on the NICE guidance, below is details
of the criteria
‘The guidance states that people with Type 1 diabetes aged 12 years or over
could have access to insulin pump therapy if they are experiencing “disabling
hypoglycaemia” or have an Hba1c of 8.5 per cent or greater whilst using multiple
daily injections (MDI) despite trying to achieve good control. Children under 12
with Type 1 can have access to insulin pump therapy if MDI are considered
impractical or inappropriate. However, once they reach the age range of 12–18,
they will be expected to have a trial of MDI if they did not do so prior to starting to
use a pump.’ Diabetes UK 2008
Hypoglycaemia Management
What is the definition of a hypoglycaemia? List some of the signs and
symptoms of a mild, moderate and severe hypoglycaemic event.
What is the educational advice given to a patient to manage
hypoglycaemia?
What dangers does a patient experience when having a severe
hypoglycaemic event?
SICK DAY RULES
Listed below are some golden rules to follow when a diabetes patient is unwell or
advice to give diabetes patients. These are taken from the BD’s sick day rules and
are written with direction to the patient.
Never stop taking your insulin even if you are ill and cannot eat.
Measure your blood glucose level more frequently, at least 4 times a day,
and adjust your insulin dose if necessary.
Try to drink plenty of liquids such as water or sugar-free drinks. At least 3 to
4 litres should be sipped through the day if possible.
If you don’t feel like eating solid food, try alternatives like milk, soup, cereals,
ice cream, pudding, fruit juice or fizzy drinks.
(Type 1) Test for blood ketones frequently as it will give you the first warning
of either a lack of insulin or carbohydrates.
Contact your diabetes centre, GP, NHS 24 or Accident & Emergency if
unsure, vomiting, don’t improve quickly or worrying.
MOST IMPORTANTLY, NEVER STOP TAKING YOUR INSULIN UNDER ANY
CIRCUMSTANCES.
What are ketones?
Currently there are restricted clinical areas that practitioner’s assess a patient’s
capillary blood ketones. The restricted clinical area is the diabetes centres. The
only glucometer that records capillary blood ketones is the Optium Exceed meter.
Patients have access to these meters and can check for blood ketones in the
community. The patient is advised to take the action detailed in the table below
with the corresponding ketones reading.
These are ranges for adults and children.
BLOOD KETONES
ACTION
More than 0.6mmol/l (Only if on an
Phone diabetes centre/Diabetes
insulin pump CSII or pregnant)
Specialist Nurse
Above 1.0mmol/l
Phone diabetes centre/Diabetes
Specialist Nurse.
Testing urine is an alternative method of monitoring ketones at home. If the
ketostix (urine testing strips) record a moderate or large content of ketones,
patients are advised to contact the diabetes centre. This is not a monitoring
method used in acute environments due to the 4 hour lag in detecting ketones.
TYPE 2 DIABETES MELLILITIS (DM)
The vast majority of patients with diabetes have type 2 and type 2 diabetes is a
different condition from type 1, therefore aspects of their medical treatment are
different from type1 DM.
The initial assessment would include lifestyle which is one of the major influences
on the management of diabetes. Adopting a healthy lifestyle can have a
significant impact on the progression of an individual’s diabetes. What is the
definition of a healthy lifestyle?
What aspects of an individual’s lifestyle are assessed and why? What are the
cardiovascular risk assessments carried out and their relevance to the individual
and their diabetes?
What weight reducing options are available to patients living in Fife including
pharmaceutical/surgical interventions?
Remember to assess for smoking, alcohol and exercise, advise
accordingly.
If lifestyle interventions do not have a significant impact on glycaemic control, oral
hypoglycaemics are the next stage in the treatment of type 2 diabetes.
ORAL HYPOGYLAEMIC AGENTS (OHA)
First line OHA
BIGUANIDES
E.g. METFORMIN 500mg, 850mg, 1000mg tablets (Maximum daily dose 3gms
but evidence supports 2gm in divided doses)
Formats: tablets, liquid, powder
METFORMIN Modified Release (MR) – (Glucophage slow release)
What is its action?
What are the main side effects?
When would metformin not be considered or temporarily stopped?
There are exceptions, Metformin should be omitted in acute
sepsis/dehydration/vomiting & diarrhoea/ etc anything that may cause acute renal
failure. The other exception that would need to be considered is if a patient with
type 2 diabetes had blood glucose levels within an acceptable range, but they are
not taking their normal dietary intake. Please consider whether oral
hypoglycaemics may need temporary discontinuation.
SULPHONYLUREAS
E.g. Gliclazide 80mg tablets ((Diamicron) Maximum daily dose 320mg and the
safest with renal failure)
Format: Tablets
Gliclazide 30mg modified release (Diamicron maximum daily dose 120mg)
Glipizide 2.5mg, 5 mg tablets ((Glipizide, Glibenese and minodiab)
Maximum daily dose 15mg)
Format: Tablets
What is its action? And mechanism?
What are the main side effects and patient education?
DPP-4 INHIBITOR (Gliptins)
E.g. Sitagliptin 100mg tablets ((Januvia) Maximum dose 100mg dose daily)
Vildagliptin 50mg tablets (Galvus)
Saxagliptin 5mg tablets ((Onglyza Maximum dose 5mg dose daily)
What is its action? And mechanism?
What are the main side effects and patient education?
THIAZOLIDINEDIONES (TZD or Glitazones)
E.g. Pioglitazone 15mg, 30mg and 45mg tablets ((Actos, Competact) Maximum
daily dose 45mg)
Format: Tablets
What is its action? And mechanism?
What are the main side effects and patient education?
GLP
E.g. Exenatide 5mcg and 10mcg subcutaneous injections (Byetta) maximum
daily dose 20mcg
Liraglutide 0.6mg, 1.2mg and 1.8mg variable dosage pen (Victoza)
maximum daily dose 1.8mg
Exenatide 4mg weekly injection subcutaneous injection (Bydureon)
What is its action? And mechanism?
What are the main side effects and patient education? Can you identify any
differences between the two GLP-1s?
Combined therapies
There are some OHAs which are a combination of two OHAs (helps with
compliance). Examples are; Competact : combination of pioglitazone and
metformin.
RESEARCH, DEVELOPMENT AND HEALTH PROMOTION
Health Promotion and Health Education
Structured education is recognised, by NHS NICE guidelines and Diabetes UK, as
important aspect of diabetes care. There are many patient education
programmes. Examples are Dose Adjustment For Normal Eating (DAFNE) and
Diabetes Education and Self Management for Ongoing and Newly Diagnosed
(DESMOND). Can you briefly explain ‘structured education’?
Diet/Carbohydrate Counting
Carbohydrates are an essential component of everyone’s diet; providing the
energy we require for daily activity and cell function. They also affect blood
glucose levels. Please give examples of various carbohydrates.
Effective diabetes care depends on carbohydrate counting and adopting healthy
eating principles. Please request time with a dietitian to understand the
commitment required to carbohydrate. It should be noted that not all patients with
diabetes are taught or encouraged to carbohydrate count; they are encouraged to
follow a healthy diet.
Exercise
Another aspect of a healthy lifestyle is the suggested Government guidelines of
completing 5 times 30 minute of vigorous exercise. Insulin adjustments or extra
carbohydrate maybe are required when undertaking physical activity.
ACUTE AND CHRONIC COMPLICATIONS OF DIABETES
There are many complications associated with diabetes, why are diabetes
patients at greater risk?
Can you explain the relationship of the following conditions with diabetes,
and the relevant examinations/test.
RETINOPATHY
HYPERTENSION AND NEPHROPATHY
HEART DISEASE & CEREBRAL VASCULAR ACCIDENT
PODIATRY / NEUROPATHY
ERECTILE DYSFUNCTION
RISKS ASSOCIATED WITH PREGNANCY
WARD RELEVANT INFORMATION
Top tips and frequently asked questions to the inpatient diabetes nurse.
When to test? Pre meal blood glucose monitoring only; and the frequency will
depend on whether the patient’s diabetes is stable or not. The only exception
would be if the patient is on a continuous sliding scale of insulin, then blood
glucose monitoring is required on an hourly basis.
Quality control. Ensure that you have been assessed as competent prior to
using the lactometer device. It is the ward’s legal responsibility to ensure daily
quality control testing is performed on all of their glucometers. This will ensure
patient safety and accurate treatment decisions are being made. Prior to use
check that the daily quality control has been done or perform the test yourself.
Hospital diet. Please ensure that the patient is informed of the diabetic dietary
options on the menu and how to obtain additional snacks as required.
Hospital diabetes. Blood glucose control tends to be erratic or higher whilst in
hospital with ill health, stressful environment and with some of the treatments, i.e.
steroids. Please also observe some sensitivity when a patient has been given a
difficult diagnosis/prognosis.
Please ascertain details of diabetes patient management with the following
presentations:
Managing Diabetic Ketoacidosis (DKA)
Managing Hyperosmolar non-ketotic acidosis Coma (HONK) or
Hyperosmolar hyperglycaemic (HHS)
Managing intravenous insulin
Managing fasting patients
MEMBERS OF THE MULTI-DISCIPLINARY TEAM
Consultants
Dr John Chalmers
Dr Louise Osborne
Dr Catherine Patterson
Dr Catronia Duncan
Dieticians
Carol Franks (VHK)
Sue Hutchison (VHK)
Julie Nicol (paeds)
Gill Malcolm (QMH)
Katie Duncan
Retinal Screeners
Lyndsay Davidson
Jennifer Hunter
Brad Smith
June Noble
Ophthalmologists
Dr Caroline Styles
Dr Ann Sinclair
Diabetes Specialist Nurses
Fiona Jamieson
Jeanette Baird
Denise Burns
Claire Henderson
Karen Moir (Adults/Paeds)
Sharon Robertson (Inpt)
Linda Robertson (Paeds)
Clinical Support Workers
Liz Arbuckle
Shirley Ross
Podiatrists
Fiona MacMillian (VHK)
Gillian Meldrum (QMH)
Angela Green (QMH)
Diane Snell (QMH/VHK)
Medical Secretaries/Admin Support
Jennifer Thomson
Claire Meadows
CONTACTS FOR THE COMMUNITY TEAMS
Community Diabetes Specialist Nurses (CDSN) has been in post since 2002.
They were introduced to improve the care of people with diabetes in primary care.
Dunfermline and West Fife
Carnegie Clinic. Tel No 01383 722911
Donna Clark Diabetes Nurse Specialist
Kirkcaldy and Levenmouth
Kinghorn Surgery. Tel No 01592 892004
Caroline Craig Lead Diabetes Nurse Specialist
Glenrothes and North East Fife
Ladybank Surgery. Tel No. 01592 769090
Hazel York Diabetes Nurse Specialist
RELEVANT GUIDELINES, RESEARCH ARTICLES and WEBSITES
The Fife Diabetes Handbook 2008 (Intranet)
Diabetes UK (Website)
National Institute for Clinical Excellence (NICE) specific regular guidelines on
Type 1Diabetes Mellitus, Type 2 Diabetes Mellitus, paediatric diabetes, diabetes
foot care, diabetes neuropathy and preconception care
Scottish Intercollegiate Guidelines Network (SIGN) No.116 (Website)
www.nhs.uk/pathways/diabetes/pages/landing.aspx
www.diabetesuffolk.com
www.runsweet.com
www.diabetes.nhs.uk
CONTACT LIST FOR DIABETES STAFF REGARDING STUDENT
NURSES
Gillian Hutchison, Practice Education Facilitator
Trish Anderson, Practice Education Facilitator
Ext 8068
Ext 8068