MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

I. Diagnostic Exams Used to Diagnose Diabetes Mellitus

Diagnostic Exams that Require Fasting A. Fasting Plasma Glucose Test It is a carbohydrate metabolism test which measures plasma, or blood, glucose level after a fast Fasting means after not having anything to eat or drink except water for at least 8 hours before the test This test is usually done first thing in the morning, before breakfast and checks your fasting blood glucose levels Diabetes is diagnosed at 126 mg/dL Purposes: To screen for diabetes mellitus and prediabetes To monitor drug or diet therapy in the patient with diabetes mellitus To monitor for hyperglycemia and hypoglycemia Nursing Considerations: Before the Test Confirm the patients identity using two patient identifiers according to facility policy Explain to the patient the purpose of the test Inform the patient that the test requires a blood sample, and explain that he may experience slight discomfort from the tourniquet and the needle puncture Instruct the patient to fast for 8 to 12 hours before the test Tell the patient to withhold his use of insulin or OHA until after the test is done, unless ordered otherwise During the Test Perform a venipuncture and collect the sample in a 5mL clot activator tube After the Test Send the sample to the laboratory immediately or refrigerate if delayed Apply direct pressure to the venipuncture site until bleeding stops Provide a balanced meal or a snack Instruct the patient that he may resume his usual medications that were discontinued before the test, as ordered

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

B. Oral Glucose Tolerance Test It is a two-hour test that checks your blood glucose levels before and 2 hours after you drink a special sweet drink. It is the most sensitive method of evaluating borderline Diabetes Mellitus cases Diabetes is diagnosed at 200 mg/dL Purposes: To confirm Diabetes Mellitus in selected patients To help diagnose hypoglycemia and malabsorption syndrome Nursing Considerations: Before the Test Confirm the patients identity using two patient identifiers according to facility policy Explain to the patient the purpose of the test Instruct the patient to maintain a high-carbohydrate diet for 3 days and then to fast for 8 to 12 hours before the test, as instructed by the physician Advise the patient that this test requires 5 blood samples and usually 5 urine specimens Suggest to the patient to bring a book or other quiet diversion with him to the test because the procedure usually takes 3 hours but can last as long as 6 hours During the Test Perform a venipuncture to obtain fasting blood sample Collect a urine specimen at the same time if your facility includes this as part of the test After collecting these samples and specimens, administer the oral glucose test load and record the ingestion time. Encourage the patient to drink the entire glucose solution within 5 minutes Draw blood samples 30 minutes, 1 hour, 2 hours, and 3 hours after giving the loading dose of glucose. Collect urine specimens at the same intervals Encourage the patient to drink water throughout the test to promote adequate urine excretion After the Test Send the sample to the laboratory immediately or refrigerate if delayed Apply direct pressure to the venipuncture site until bleeding stops Provide a balanced meal or a snack Instruct the patient that he may resume his usual medications that were discontinued before the test, as ordered

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

Diagnostic Exams that do not Require Fasting A. Random Plasma Glucose Test It is also known as Casual Plasma Glucose Test This test is a blood check at any time of the day when you have severe diabetes symptoms Diabetes is diagnosed 200 mg/dl Nursing Considerations: Before the Test Confirm the patients identity using two patient identifiers according to facility policy Explain to the patient the purpose of the test Inform the patient that the test requires a blood sample, and explain that he may experience slight discomfort from the tourniquet and the needle puncture During the Test Perform a venipuncture and collect the sample in a 5mL clot activator tube After the Test Send the sample to the laboratory immediately or refrigerate if delayed Apply direct pressure to the venipuncture site until bleeding stops B. Hemoglobin A1C Test The A1C test measures your average blood glucose for the past 2 to 3 months High levels reflect inadequate diabetic control The advantages of being diagnosed this way are that you dont have to fast or drink anything Diabetes is diagnosed at 6.5% Nursing Considerations: Before the Test Confirm the patients identity using two patient identifiers according to facility policy Explain to the patient the purpose of the test Inform the patient that the test requires a blood sample, and explain that he may experience slight discomfort from the tourniquet and the needle puncture During the Test Perform a venipuncture and collect the sample in a 5mL clot activator tube Gently invert tube several times to mix the anticoagulants

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

After the Test Send the sample to the laboratory immediately or refrigerate if delayed Apply direct pressure to the venipuncture site until bleeding stops SUMMARY

Indicator Fasting plasma glucose

Normal

Pre-diabetes

Diabetes

< 100 mg/dl 100-125 mg/dl 126 mg/dl or greater

OGTT 2 hr. post glucose-rich < 140 mg/dl 140-199 mg/dl 200 mg/dl or greater beverage

Casual or random plasma glucose and symptoms

200 mg/dl or greater

A1c

<5.7%

5.7-6.4%

6.5% or greater

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

II. Physical Assessment

General Assessment A. Patients with Altered Consciousness Must check for: Mental State Pulse Blood Pressure Respiration State of Hydration (Skin and Mucus Membrane) B. Patients in Non-acute setting Must check for: Mental State Pulse Blood Pressure Respiration State of Hydration Measure BMI BMI >23 kg/m2 is over weight BMI >30 kg/m2 is obese Measure Waist to Hip Ratio Formula: Waist circumference divided by hip circumference For males: <0.95 is low risk >1 is high risk For females: <0.8 is low risk >0.85 is high risk Measure Orthostatic Blood Pressure

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

Loco Regional Assessment A. Examination of Head and Neck Xanthelasma The appearance is of yellow flat plaques over the upper or lower eyelids, most often near the inner canthus They represent areas of lipid-containing macrophages but the exact pathophysiology is not known About half of xanthelasma cases are associated with elevated plasma lipid levels; Secondary hyperlipidemia can also be an association, usually caused by underlying uncontrolled diabetes Cranial Nerve Palsy (3, 4, 6, and 7)/ Cranial Nerve Mononeuropathies It classically presents with an abrupt onset and is characterized by transient pain, absence of other neurologic involvement and spontaneous recovery in 36 months Ptosis It is an abnormally low position (drooping) of the upper eyelid Hirsutism It is a male-type hair in a male distribution pattern (groin, trunk, face and chest) in a woman or teenage girl Because of the link between obesity and hirsutism, this condition also can be found in Type 2 diabetics Carotid Bruit It is a murmur heard over the carotid artery in the neck, suggesting arterial narrowing It is usually secondary to atherosclerosis B. Examination of the Eyes Corneal Arcus It is a white or gray opaque ring around the edge of the cornea, or colored part of the eye It is related to diabetes, high blood pressure and high cholesterol Cataract A cataract is a clouding or fogging of the normally clear lens of the eye Although anyone can get cataracts, people with diabetes get these eye problems at an earlier age than most and the condition progresses more rapidly than in people without diabetes Symptoms of this eye problem in diabetes include blurred or glared vision

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

C. Examination of Buccal Cavity Inspect for: Puffy red gums Build up of plaques Obviously decayed teeth Typical bad breath or periodontitis D. Examination of Skin and Nail Necrobiosis Lipoidica Diabeticorum It occurs when collagen breaks down, deposits of fat build up and the blood vessel walls thicken It indicate a possible connection between NLD and damage to small blood vessels that might result from diabetes It appears as a rash most often on the lower legs, but some people might notice it on their face, torso, scalp or arms Granuloma Annulare It usually presents with little spots or papules on the hands or feet but it is a harmless and self-limiting problem that almost always settles with time and no treatment It is more common in diabetes because of the disturbance it causes with the carbohydrate-lipid metabolism, small blood vessel damage and involvement of nerves It can recur occasionally and follow the same pattern Acanthosis Nigricans A condition characterized by discolored patches in the skin folds of the armpits, neck, or groin, ranging from tan to dark brown Acanthosis nigricans is associated with hyperinsulinemia which results from obesity-related insulin resistance Acanthosis nigricans is often an important early marker of Type 2 diabetes or evidence that a person has a high risk of developing the condition Diabetic Dermopathy This harmless condition appears due to changes in the blood vessels The skin may develop brownish, circular patches that take on a scaly appearance Diabetic dermopathy typically appears on the fronts of both legs and is more common in people who are over the age of 50, especially in those with high HbA1c levels and in those with other complications

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

Bullosis Diabeticorum This is an uncommon condition in which blisters occur on the hands and feet and sometimes also the legs and forearms The blisters are unrelated to trauma or infection; they develop spontaneously and may become quite large They are usually not painful and typically heal without scarring in several weeks E. Examination of the Hands Diabetic Cheiroarthropathy It is also known as diabetic stiff hand syndrome or limited joint mobility syndrome This syndrome is characterized by thick, tight, waxy skin reminiscent of scleroderma Limited joint range of motion (inability to fully flex or extend the fingers) and sclerosis of tendon sheaths are also seen One indication of the presence of this condition is known as the prayer sign- inability to press their palms together completely without a gap remaining between opposed palms and fingers Dupuytens Contracture It results from a thickening, shortening, and fibrosis of the palmar fascia Flexion contractures of the fingers may result, usually at the fourth finger, but sometimes involving any of the second through fifth digits Its pathogenesis is thought to be the same as that for cheiroarthropathy Tinels sign It is done by tapping over the median nerve on the volar aspect of the wrist A positive Tinels sign produces paresthesias distally in the hand Phalens sign It is done by flexing the wrist for 30 to 60 seconds A positive Phalens sign consists of paresthesias being reproduced in the hand with this maneuver

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

F. Examination of Injection Sites Assess the: Anterior abdominal wall Upper thigh/buttocks Upper outer arm Possible Findings: Bruising Lipodystrophy G. Examination of the Abdomen Possible Findings: Hepatomegaly It is due to non-alcoholic fatty liver disease Abdominal Tenderness (in DKA) H. Examination of Legs Possible Findings: Calf and Thigh muscle wasting Sensory abnormality Dry skin and Hair loss Absent/Weak Femoral pulse Femoral Bruit Loss of Knee/Ankle Jerks I. Examination of Feet Charcot Neuroarthropathy It is a condition involving destructive, lytic joint changes It is a severe, destructive form of degenerative arthritis resulting from a loss of sensation (brought on by underlying diabetic neuropathy) in the involved joints It most commonly affects the pedal bones Inspect for: Callus Loss of plantar arch Diabetic foot ulcer Fungal Infections Peripheral Pulse Palpated at posterior tibial artery and arteria dorsalis pedis Tests for Sensation Light Touch using Monofilament Crude Touch using blunt end of pin Pain using tip of prick Temperature Vibration using 128 Hz Tuning fork Proprioception Sense of self

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

III. History
A. Medical History What type of Diabetes do you have? Duration of Diabetes How was your diabetes being diagnosed? Did you have excessive thirst and urination? How was your diabetes treated initally? How do you rate your control of your diabetes over the years? How do you rate your control of your diabetes in the past few weeks? What diabetes education have you had in the past? What sort of diet do you follow now? What has happened to your weight since you were diagnosed with diabetes? Have you had a recent measurement of your blood glycohemoglobin level (this test tells us what your average blood sugar level has been for the past 3 months)? Do you test your own blood sugar levels? How high have your blood sugars been on average recently? Do you exercise regularly? What type? Have you ever had ketoacidosis (extremely high blood sugar levels, nausea, vomiting, and rapid breating requiring hospitalization)? Have you ever had extremely low blood sugar levels causing unconsciousness? Have you had problems with infections? Ask for complications of diabetes Retinopathy Neuropathy Nephropathy Cardiovascular problems Diabetic Foot Ask medication history? Compliance to OHA or Insulin Any allergies to medication B. Social History Marital Status Occupation Do you drink? How often? Do you smoke? How many packs? How long?

Prepared by: Mark Anthony T. Tabago, RN

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MSN- AHN 202

[DIABETES: DIAGNOSTIC EXAMS, PHYSICAL ASSESSMENT, AND HISTORY TAKING]

C. Family History Ask patient to list family members with Diabetes mellitus Cancer Stroke Thyroid Disease
(See attached copy of New Diabetic Patient Medical History Information for check list of history taking)

Prepared by: Mark Anthony T. Tabago, RN

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