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.
- to have responsibility for individual patients who are registered with
- 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
- 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
- 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
- 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.
- 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
- 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. Dont 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 patients 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,
- 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
- 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 patients 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.
- Blood Glucose between 4 - 8 (tight control - discuss extra risks of hypos
- Blood Glucose between 4 - 10 (acceptable control particularly in older
- 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
- Patients 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
- 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)
- Habits - ? Smoking ? alcohol intake
- Feet - test for pulses (quality and quantity); vibration and sensation;
- 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
- 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- dont forget
potential problems such as impotence).
- Record all findings and points covered in notes and patients
- 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
- HbA1c; B.P.; Weight; compliance.
- Address patients needs and concerns
- 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
- Discuss with patients - their concerns and well being
- Check nurses findings and if appropriate re-examine
- Discuss patients targets in relation to laboratory results
- Alter therapy if necessary
- Target risk factors - add hypotensives, lipid lowering drugs, aspirin
- Treat complications
- Address any other concerns
- Discuss future targets
- Refer to secondary care if necessary
- Update notes and alter recall markers if felt necessary
- Update patients 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
- 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
- Diet the role of fats and sugars
- BM and relate to diagnosis, cause and target needed
- Smoking - effects, especially in relation to diabetes
- Weight - effect of obesity on diabetes insulin resistance See
- 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
- Patients well being and concerns
- Home monitoring results
- Relate to diet and exercise - try to illustrate cause and effects from
- 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.
- 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.
- 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