Professional Documents
Culture Documents
MANUAL
7th Edition
ISBN: 978-0-9756985-7-0
616.462
Acknowledgements
EDITORIAL TEAM 7th Edition 2009
Diabetes is and continues to be a significant and rapidly growing global public health
issue and in fact could be viewed as a disease in the numbers akin to an epidemic.
Type 2 diabetes affects over 6% of the Australian adult population and makes up about
85 90 % of all diabetes. Type 1 diabetes makes up about 10 15 % of all diabetes
and is increasing at a rate of approximately 3% per year. Gestational diabetes affects
4.9 % of all pregnancies and is a significant risk factor for the development of type 2
diabetes later in life.
In Australia, diabetes is the second most common reason for renal dialysis, the most
common cause of blindness in people over the age of 60 years, the most common
cause of non-traumatic amputation and one of the more common chronic diseases
amongst children.
I commend this manual to you the user and trust that you will find it informative and
useful and encourage you to introduce other health professionals to it to assist them in
managing their clients and patients. This manual is a very valuable resource tool in the
management and continuing education for individuals with diabetes.
Section 4 Hospitalisation
Section 6 Footcare
Section 10 Medication
Section 15 Resources
Section 16 Reference
SECTION 1
Introduction
Preface
This manual has been developed by a team of health professionals working in the area
of diabetes care.
Diabetes Your Hospital Manual was originally an initiative of the staff of The Queen
Elizabeth Hospital Diabetes Centre. The original publication in 1990 was aimed at
documenting in-house hospital policies to assist staff in developing comprehensive and
effective care for people with diabetes during hospitalisation.
Since that time the Manual has been updated to incorporate nationally accepted
guidelines. Diabetes Outreach aims to disseminate this information for use in a range
of hospitals and health care settings particularly in rural and remote areas. The
information contained in this manual should be used in conjunction with current local
policies and protocols.
Users of the manual are welcome to submit any suggestions for its improvement to
Diabetes Outreach.
Should you have any queries about the contents of this manual contact:
Diabetes Outreach
8 Woodville Road,
WOODVILLE SA 5011
Telephone: (08) 8222 6775
Facsimile: (08) 8222 6768
An improvement in the quality of diabetes health care and education provided by health
care providers is the desired outcome.
A reference list is provided at the end of each section and a glossary is included at the
end of the manual. Users of the manual are free to photocopy any relevant information
that will assist them in caring for people with diabetes.
The manual is also available online and can be downloaded free of charge at
www.diabetesoutreach.org.au.
Example:
A person with newly diagnosed diabetes mellitus is in hospital for minor surgery.
! Find the problem / situation - the person has no knowledge of what diabetes is
and needs a basic introduction of diabetes while in hospital.
! Do what is suggested
! Evaluate outcome - has the person a simple understanding of what diabetes is?
Are there any areas that need explaining? (Evaluation may lead to identification
of a new situation / problem which requires further action).
The starting point for a primary health care approach is to provide a complete system
of care to address the communitys main health problems that is, those which are the
most common and which have the most significant impact on the health status of the
community.1
The World Health Organisation defines primary health care as having the following
broad ideals:
! it is the first level of contact for individuals and communities with the health
system
! is located as close as possible to where people live and work
! is universally accessible - no barrier of cost, geography, culture, race, gender or
other barriers
! is based on full participation of the community
! emphasises prevention
! addresses the main health problems of the community it serves
! is the main focus of a countrys health system - not a bottom layer added on.
WHO2
The Declaration of Alma-Ata defined primary health care as: Primary Health Care is
essential health care based on practical, scientifically sound and socially acceptable
methods and technology made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and country
can afford to maintain at every stage of their development in the spirit of self-reliance
and self-determination.2
Trying to create an environment that makes `healthy choices, easy choices' (access to
healthy food, exercise options etc).
Factors affecting health include physical factors, social status, cultural issues,
economic situation and gender environment.
Group/family Community
Individual
Policies Social/Economic
Promote health
Promoting exercise, high fibre, low saturated fat, low added sugar eating as the
normal pattern for the health of all Australians.
Prevent illness
Encourage people to find out whether they are at risk of developing type 2 diabetes, eg
do they have a family history, are they overweight or over 40 years.
Minimise disability
For those who have diabetes (any type), have regular checks with the appropriate
health professionals for early detection and prevention of complications.
Equality of access
Equity of outcome
Targeting population(s) who are most at risk of developing type 2 diabetes (eg
Aboriginal).
Overcoming isolation
Provide opportunities for people with diabetes to interact and network with others, eg
support groups.
Disease control
Provide information for all people with diabetes about the range of services / treatments
available.
SECTION 1 INTRODUCTION REVISED SEPTEMBER 2009
4
The process of evaluation
These are some of the steps to be considered in evaluation:
Evaluating the work of your agency or team is a vital process to prevent it wandering
from its original goals or away from addressing the needs of the community you are
working for. Informal evaluation can be incorporated into the normal work of the
agency or team, for example, through discussion and reflection at weekly staff
meetings. It will be necessary, however, for the agency or team to take time out to
evaluate itself more formally, and to involve the community in this process. This can be
done by setting time aside specifically for evaluation and strategic planning.3
Remember the most important member of the team is the person with diabetes.
Diabetes mellitus is one disorder where most of the care is provided by the individual
themselves. The individuals knowledge, skills and attitude for behavioural change are
the essential ingredients of optimal self-care.
To improve health and the quality of life, we, the health professionals involved in
diabetes care, have a responsibility to provide ongoing expertise, information and
psychological support to individuals with diabetes.
2. World Health Organisation (1978) Report of the International Conference on primary health care -
Alma-Ata, USSR. World Health Organisation, Geneva.
3. Wass A (2000) Promoting health: The primary health care approach. Harcourt Australia,
Marrickville.
Glucose is needed by the body for energy and is obtained from carbohydrate foods
such as starches and sugars. The glucose is transported from the gut through the
portal system to the body. Glucose that is not immediately used is transformed and
stored in the liver. The regulation and storage of glucose is controlled by the hormone
insulin.
Insulin is produced by the beta cells of the pancreas in response to a rise in blood
glucose concentration. The hormone insulin is responsible for the uptake, storage and
use of glucose by the body cells, thus supplying available energy for use in the body.
Without sufficient insulin there will be impaired metabolism, not only of carbohydrates,
but of protein and fats as well.
Classification of diabetes
The different types of diabetes have different causes and clinical presentation. The
common feature for all types of diabetes is hyperglycaemia.
Primary diabetes
Gestational diabetes
Diabetes occurring for the first time during pregnancy and often lasting only for the
duration of the pregnancy. Progression of type 2 diabetes later in life will occur in
550% of women with gestational diabetes mellitus (GDM). Around 17% of Australian
women with GDM develop type 2 diabetes within 10 years, and up to 50% within 30
years.2
Secondary diabetes
generally occurs in younger people under usually occurs in older people over 40
40 years but may occur at any age years, may occur at any age
Onset
rapid onset (weeks / months) gradual onset, often no symptoms
(months or years)
ketonuria often present (due to lack of ketonuria not present as some insulin still
insulin) being produced
Treatment
requires intensive insulin therapy either by initially life style education, and will
multiple injections or insulin pump require oral medication and/or insulin
therapy after a few years
The treatment is similar to the approach with adults eg lifestyle and medication.
Diagnosed 3.8%
Undiagnosed 3.8%
IGT of IFG 16.3%
Total 23.9%
The prevalence of type 2 diabetes rises steeply with age and is estimated at:
25 34 years 0.3%
35 34 years 2.5%
45 54 years 6.2%
55 64 years 13.1%
65 74 years 18.6%
75 years plus 23.6%
The latest report published by the Australian Institute of Health and Welfare shows that
the rate of type 1 diabetes is increasing by 3% per year.5
! polyuria
! polydipsia
! tiredness / lethargy.
The symptoms of diabetes vary from individual to individual and in relation to the level
of hyperglycaemia. Some people with type 2 diabetes may also be asymptomatic.
Symptoms are similar in each type of diabetes, however, intensity and onset varies.
Glycosuria the presence of glucose in the urine. When blood glucose concentration
exceeds the renal threshold of approximately 10mmol/L in a young person (in older
people it can be higher) glucose is excreted in the urine and is detected with a reagent
testing strip.
Polyuria excessive urination. Glucose is osmotically active and requires water for
excretion. In uncontrolled diabetes, the filtered glucose `pulls large quantities of water
with it which leads to increased urine production.
Weight Loss in type 1 diabetes, protein and fat stores are broken down to be used
for energy. Ketones are produced and excreted in the urine.
Ketonuria in type 1 diabetes there may be the presence of ketones in the urine or
blood. When there is not enough insulin to utilise the glucose, fat stores are broken
down for energy, ketones are produced. Moderate to large ketones found in urine or
blood may indicate ketoacidosis, a life-threatening emergency situation.
Blurred vision due to change in the shape of the lens of the eye because of
hyperglycaemia. Occasionally this is the main symptom and may last several weeks
while blood glucose is being stabilised.
Testing for undiagnosed type 2 diabetes is recommended for the following high risk
Individuals:6
Individuals presenting the following risk factors are also considered to be at high risk of
having undiagnosed type 2 diabetes:
Diagnosis
Diagnosis is made in one of the following ways but each must be confirmed on a
subsequent day unless unequivocal hyperglycaemia with obvious symptoms are
present.
3. 2-hour plasma glucose >11mmol/L during an oral glucose tolerance test (OGTT).
The test is carried out after an overnight fast, following three days of adequate
carbohydrate intake (greater than 150g per day). A 75g load of oral glucose is given
and the diagnosis of diabetes can be made if venous plasma glucose level fasting is
>7.0mmol/L or 2 hour post glucose load is >11mmol/L.
F: 5.5-6.9 F: "7.0
F or R:<5.5 R: 5.5-11.0 R: "11.1
Re-test yearly if
high risk Oral glucose tolerance test
3 yearly if
increased risk 2hr glucose levels
F = Fasting
R = Random Impaired glucose tolerance
A person with type 2 diabetes may first present with long term complications - eg
diabetic retinopathy, neuropathy, coronary artery disease, peripheral vascular disease
and / or cataracts (refer Long term complications Section 12).
A team approach is essential for the successful management of diabetes, with the
active participation of the person with diabetes and if appropriate including family
members.
! active involvement of the person with diabetes and their family members
! appropriate treatment plan
! appropriate nutrition and weight control
! appropriate exercise / activity program
! advice for maintaining a healthy lifestyle eg stress management, avoiding
smoking
! appropriate safe use of pharmaceuticals as required (oral agents and / or insulin).
! restore the altered metabolism of the person with diabetes and maintain blood
glucose levels within the normal range
! identify and reduce risk factors of diabetes related complications
! prevent or delay progression of the short and long term complications
! empower the person to self manage their own diabetes and restore the individual
with diabetes to as independent a lifestyle as possible
! provide ongoing management, support and resources.
! people with type 2 diabetes usually progress from lifestyle alone, tablets and then
onto insulin8
! type 2 diabetes is a progressive disease which needs progressive increases in
treatment to maintain appropriate HbA1c levels
! oral medications can be combined with insulin.
Type 1 diabetes can be diagnosed if the characteristic symptoms and signs are present
and the fasting venous plasma glucose concentration is greater than or equal to
7.0mmol/L, and / or the random venous plasma glucose concentration taken at least 2
hours after eating is greater than or equal to 11.1mmol/L. An oral glucose tolerance
test (OGTT) is rarely indicated in diagnosis of type 1 diabetes in childhood and
adolescence.3 A child or adolescent may present with diabetic ketoacidosis (refer
Unstable diabetes Section 7).
The honeymoon period is the time between diagnosis and complete damage to
the beta cells of the pancreas. Initially the persons pancreas is still producing
some insulin but in decreasing amounts. The person may go from not needing
much insulin to needing some insulin, to being totally dependent on insulin
within a year.
How long the honeymoon period lasts varies from person to person but people with
type 1 diabetes will usually be totally dependent on insulin within one year.
! Children and adolescents with type 1 diabetes should have access to care by a
multidisciplinary team trained in childhood diabetes.
! The older child and the family should be recognised as being part of the
management team.
! Education from a credentialled diabetes educator (where possible) should be part
of the management of type 1 diabetes.
! Education should be adapted to each individuals age, maturity, stage of
diabetes, lifestyle and culture.
! After the initial period of diagnosis and education (when frequent contact may be
required), the child should be regularly reviewed throughout the year. This should
be no less than 3-4 times per year), including one major annual review (paying
particular attention to growth, blood pressure, puberty, associated conditions,
nutrition and complications) with the multidisciplinary team.
! In rural and remote areas children with diabetes may be successfully cared for by
a local paediatrician / physician with training and experience in paediatric
diabetes, access to resources, support and advice from a tertiary centre diabetes
team.
! The transition from a paediatric to an adult service for the adolescent with
diabetes is often difficult. Transfer to an adult service should be comprehensive
and include a preparation phase and evaluation phase.3
Diagnosis
Indications
1. To confirm diabetes when fasting blood tests are inconclusive.
Considerations
! Recent illness may give false glucose tolerance test results, therefore it is
preferable to perform the test after at least 2 weeks of good health.
! Adequate dietary carbohydrate for the 3 days prior to the test (! 150g/day). In
most cases this means that the person should have their usual diet.
Preparation
! The test is performed in the morning, after a fast of at least 8 hours (but not more
than 16 hours).
! The person is advised to rest for 30 minutes before and for the duration of the
test. (Sitting in a chair is sufficient).
! No smoking for at least one hour before the test or during the test.
The dose for children is 7ml of solution (1.84g of glucose) per kg body weight, up to a
maximum of 285ml (75g).
Procedure
Ensure appropriate pathology request form is completed by a medical officer.
Collect venous blood sample immediately before glucose drink then at 2 hours after
glucose drink.
Note times for fasting and 2 hr bloods, and label bottles correctly.
6. National Health & Medical Research Council (2001) Part 3: Case detection and
diagnosis. Evidence based guidelines for case detection and diagnosis of type
2 diabetes. December, NHMRC, Canberra.
Unlike acute medical conditions, chronic conditions are ongoing, with health outcomes
and quality of life dependent on client self management and decision making, and the
availability of ongoing (versus short term) clinical care and support services. Client-
centred approaches in chronic disease management place the person with the
condition as the expert rather than the health professional. This does not negate the
need for expert or best practice clinical management but recognises that the person
with the condition has the absolute power of veto over even the most efficacious
clinical management plan.
Diabetes has been considered as one of the most complex of the chronic diseases,
requiring the person with diabetes to juggle a range of daily clinical and lifestyle tasks
in order to avoid the short and long term complications of diabetes. Diabetes self
management education (DSME) aims to build the person with diabetes as an active
member of their diabetes team and to improve health status by empowering the
person with diabetes to;
The role of health care providers is to support people with diabetes along this path by
providing self management education and support, enabling them to master the tasks
required for effective self care and to become an active participant in their diabetes
management.
Three overarching goals for diabetes education were identified in this report that
resulted from a review of relevant literature, survey of service providers, extensive
consultation with consumers, service providers and policy makers and a national
stakeholder forum:
The outcomes associated with the attainment of these goals were identified as:
The above outcomes were defined as the results of diabetes education. Indicator
areas were identified for each outcome. Indicators are defined in the report as the
units of information that can measure progress towards achievement of the result.
The Stanford Model is underpinned by self efficacy theory which is premised on the
following: belief in ones ability to perform tasks is a good predictor of motivation and
behaviour; self efficacy can be enhanced through skills mastery, goal attainment,
modelling and social persuasion; improved self efficacy leads to improved behaviour,
motivation, thinking patterns and emotional well being. The Flinders Model also
identifies the Transtheoretical Model as a useful model to guide health professional
interventions which should be characterised by collaborative goal definition; targeting,
goal setting and planning; training and support for individuals to change; active and
sustained follow-up. The Stanford Model focuses on peer leadership and generic skill
development while the Flinders Model is clinician led and is designed to be integrated
with medical management.
With permission from the AADE, the Australian Diabetes Educators Association
(ADEA) has adopted the AADE self care behaviours and published them in Diabetes
Self Care the 7 Steps to Success.7
The self care behaviours provide an easily understood framework and a common
language for people with diabetes and diabetes educators to discuss health behaviours
and their associated risks and benefits.
The Health Belief Model8 identifies that in order to adopt a behaviour (eg engage in
self care practices), a person must believe they are at risk of an adverse event (eg
diabetes complications), that the consequences of the event are severe and that the
event can be avoided by a particular treatment or engaging in a particular behaviour.
The likelihood of a person adopting the behaviour depends on how they perceive the
benefits as opposed to the barriers (or costs) of adopting the behaviour.
Self efficacy is one of the five domains of self determination identified in the Outcomes
and Indicators Framework. Self efficacy is also one of the key constructs of Social
Cognitive Theory.8 People develop self efficacy through experiencing success.
Social Cognitive Theory embodies the following strategies for health behaviour
interventions:
The Transtheoretical Model8 identifies the various stages of change that individuals
move through in order to adopt and maintain a behaviour: pre-contemplation;
contemplation; preparation; action; and maintenance. Other important concepts of the
Transtheoretical Model are decisional balance (the benefits versus the costs of
changing) and self efficacy (confidence that one can engage in healthy behaviours
across a range of challenging situations versus temptation to engage in unhealthy
behaviours). The Model also clearly identifies that different strategies are required for
each stage of change and applying strategies suitable for one stage at another may
be counter productive. Given the range of self care behaviours that people with
diabetes are required to contemplate, it is important to recognise that individuals may
be at different stages of readiness for each one.
The NHMRC Patient Education Guideline for Type 2 Diabetes10 identifies the following:
! Both group and one-to-one diabetes client education provided on a face to face
basis have a positive impact on knowledge, lifestyle change and some aspects of
psychological outcomes.
! Interventions delivered over the longer term and those with regular reinforcement
are more effective than one-off or short term interventions.
! Multidisciplinary team delivery may provide better client outcomes.
Program aims
The overall aim of diabetes education is to support people with diabetes to acquire the
knowledge, skills and confidence to engage in effective diabetes self care practices
and be pro-active members of their diabetes care team.
To be effective, education should be designed to build on the persons own life skills
and behaviours. It should be sensitive and relevant to the individuals needs, goals
and their perception of their illness. Changing behaviour will depend on the educators
approach to the persons beliefs and the knowledge the person already has.
Educational programs should be planned bearing in mind that any illness and / or
admission to hospital can cause regression in an individuals coping mechanisms and
emotional responses. This can cloud the persons normal judgment and impede
learning.
! Having ascertained what people already know, work from that to new areas of
information.
! Having ascertained what worries or concerns the person, work to address these
as a priority.
! Demonstrate skills - person performs skill with you / person performs skills
independently with your support / supervision.
! Referring to written step by step information that person may refer to if educator
is not present.
! Leave person with written handouts on subjects covered that will reinforce the
information given or skills taught.
Accept the persons right not to follow any / all of the recommendations at the time of
teaching. They may take these up later.
For some people, the need to avoid alcohol, cigarettes, fatty foods and excess calories
conflicts with perceived rights for social acceptance, pleasure, gratification and tension
reduction.
Therefore, some people need help in substituting one value for another. A new value
must be equally rewarding if the behaviour is to be changed.
Printed text should be provided to reinforce information given and should be specific to
the areas addressed.
The first phase for evaluating a program or service can be done using a formative
approach as this will inform further adjustments/improvements to the education
program or service.
Formative evaluation
4. Surveys
! can be used at the end of each session to get a general feel for how the
clients felt after the session. See Appendix 1 for an example of a consumer
satisfaction survey.
Summative evaluation
The report Outcomes and Indicators for Diabetes Education A National Consensus
Position (Outcomes and Indicators Framework 2007) provides a framework for the
design and evaluation of diabetes education programs. Some of the outcomes related
to diabetes education from this report were identified as:
! knowledge / understanding (including the application of knowledge)
! self management
! self determination
! psychological adjustment
! clinical outcomes
Some of the tools that can be used pre and post education to assess outcomes can be
accessed via the Diabetes Outreach website www.diabetesoutreach.org.au.
You can explain the SMART goal acronym, giving examples. Goals should be:
! Specific exactly what will you do? eg I will walk for 30 minutes.
! Measurable how much / how often are you going to do this? eg three
times a week.
! Achievable how confident are you that you can do this? On a scale of 1
10, confidence should be rated at least 7, otherwise the goal may be
unattainable.
! Realistic is this something that really can be done?
! Time frame be specific about the time frame in which you are going to
achieve this eg I will achieve this by the end of next week.
We would like to acknowledge the contribution by Kaye Neylon to this section of the
Manual (2009) and her work on the 7 steps education and support program.
Did the diabetes team member(s) explain things to you in a way you could
understand?
Did you have confidence and trust in the diabetes team member(s)?
Did the diabetes team member(s) ask about how your living situation might
affect your health?
Did you ever feel that members of the diabetes team did not talk to each
other enough about your care or situation?
Did you have any follow-up visits that you felt could have been avoided by
better coordination?
Did you feel the diabetes team member(s) communicated appropriately with
your doctor?
Being active
The purpose of this module is to:
! describe the relationship between physical activity, diabetes control and risk factors for the development of complications
! discuss physical activity and exercise recommendations for people with type 2 diabetes
! discuss precautions for people with type 2 diabetes engaging in exercise
! assist participants to develop a personal physical activity plan.
Goal setting
S: Specific Specific, concrete goals to describe what the aim is.
M: Measurable Make sure there is an inbuilt measure so that it is clear when the goal has been accomplished.
A: Action oriented Make sure there is a description of how the goal will be achieved.
R: Realistic Set achievable and realistic goals that are geared towards success not failure.
T: Time-bound Goals that have a time frame can be measured and reset.
This goal clearly states what the person will be doing, when they will be doing, and for how long. It seems realistic and after four weeks it can be evaluated
and changed as required. The aim of the goal is to take small steps that will lead to the larger overarching goal of being active. If the person wasnt
reaching their goal then it is important to look at what the barriers are eg using the example above perhaps the person has been skipping their lunch break
because they have too much work to do. Whatever the reason, it's an indication that the goal needs adjusting. The person might decide to walk after
supper for twenty minutes instead. It is important to change the goals so that the person can succeed.
*Note: if the person does not score 7 (on a scale of 1-10) then they should be encouraged to re-frame their goal
6. Flinders Human Behaviour & Health Research Unit (2006) The 'Flinders Model'
of chronic condition self-management. [Cited 29 April 2009]; Available from:
http://som.flinders.edu.au/FUSA/CCTU/self_management.htm
8. Glanz Karen, Rimer B K, and Lewis F M. eds (2002) Health behaviour and
health education. 3rd Edition. John Wiley & Sons, San Francisco.
10. National Health & Medical Research Council (2008) NHMRC Patient education
guidelines: DRAFT. NHMRC, Canberra.
1. Admission procedures.
2. Diabetes management principles.
3. Peri-operative care.
4. Management for radiological procedures.
5. Inpatient diabetes management guidelines (where diabetes is a co-morbidity not
primary reason for admission).
6. Managing acute complications in hospital (hypoglycaemia, diabetic ketoacidosis
and hyperglycaemic hyperosmolar state.
7. Insulin pump therapy.
You may like to refer to the glossary and list of abbreviations contained at the back of
this section.
Admission procedure
The nursing assessment indicates the reason for admission, and should be clear if
diabetes is the reason for the admission or a co-morbidity.
! type 1
! type 2
! type 2 diabetes insulin requiring.
Assessment
Confidentiality of information and the persons privacy must be maintained.
The interview process may be conducted formally or while admitting the person, ie
during observations, ward orientation or physical assessment.
Specific symptoms:
Diabetes history:
Identifying risks:
! all people with diabetes should have an opportunity to discuss their self
management issues with qualified health professionals.
Self care
! Medications.
! Self administration of insulin.
! Hypoglycaemia action plan.
! Foot care.
! Sick day action plan.
Negotiate a management and education plan to address the identified needs with the
individual, listing objectives and expected outcomes.
Referral options
! Diabetes educator.
! Dietitian.
! Or other relevant health professionals as deemed necessary, eg social worker,
psychologist, podiatrist, vascular nurse, eye department, aboriginal health
worker.
Ensure the person is registered with the National Diabetes Services Scheme and has
adequate supplies of:
Ensure the person is aware of resources for ongoing supplies, eg Diabetes Australia,
National Diabetes Services Scheme (see Resources Section 15).
Assess the ability of the person with diabetes and the family to cope at home
and within the community.
Are they aware of their long term medical needs, monitoring and liaison with their local
doctor?
Ensure the person is aware of the role of their local doctor. The general practitioner is
often the principal medical professional, in other instances there may be a `shared-
care arrangement between specialist, general practitioner and diabetes educator.
Regular follow up visits are encouraged and offer a great opportunity for the general
practitioner to get to know the person and explore the persons understanding, fears
and concerns about diabetes.
Ensure the person is aware of where to seek assistance / advice for problems
and emergency treatment.
Subcutaneous insulin
! Supplementary basal insulin (see table 2; page 15).
! Basal / bolus intensive insulin regimen (see table 3; page 16).
! Changing usual insulin regimen (see table 4; page 17).
! Sliding scale insulin for patients who are fasting (see table 5; page 17).
Ketones
! Check for urinary or blood ketones in patients who are on insulin if BGL
persistently >15mmol/L or if the patient is very ill. 4
! If urine ketone levels 3+ or blood ketone levels are above 1.5 or ketoacidosis
suspected, contact the GP / MO or diabetes specialist (eg endocrinologist)
immediately.4
Special circumstances
Enteral or parenteral nutrition
Patients with diabetes who are commenced on enteral or parenteral nutrition may need
significant adjustments to the type, doses and / or timing of their diabetes treatment.
Patients on glucocorticoids
! Patients with diabetes who are commenced on prednisolone, dexamethasone or
other glucocorticoids will experience elevated BGLs.
! BGLs should be monitored 4 times per day and diabetes treatment intensified to
keep BGL in target.
! Remember to adjust diabetes treatment downwards as dose of steroids are
reduced and ceased.4
Pre-op care
Admission the day before surgery may be advisable to thoroughly assess and establish
monitoring and treatment plans in a person who:
People with type 2 diabetes and on Metformin should have their Metformin ceased 48
hours prior to surgery. Sulphonylureas will need to be withheld on the day of surgery
(long acting sulphonylureas such as Glibenclamide may need previous nights dose
withheld).
Management is determined by the results of blood glucose monitoring, and whether the
person is eating or not.
* ALL people with diabetes should have their blood glucose level checked within 1
hour prior to going to theatre. Report to the anaesthetist if the level is <5mmol/L or
>10mmol/L.
People with type 1 diabetes are particularly at risk from ketosis. Notify GP / MO if
ketones are present in blood or urine.
Before giving insulin to a person who is fasting make sure there is an IV glucose
infusion in place running at an appropriate rate.
Intra-op care
! The type of IV fluid given will depend on whether the person is receiving insulin
or not. Glucose infusion must be used if patient has received insulin prior to or
during surgery.
! Monitor BGL at least 2 hourly (1 hourly if IV insulin / glucose infusion in situ).
! then 4-6 hourly (or 1 hourly for continuous insulin / glucose infusion) for 24 hours
or until stable and eating
! then before meals.
! at least 8 hourly
! more frequently if blood glucose >15mmol/L, if the person is vomiting or is
generally unwell.
Before discharge, the person should be advised that their medication dosages should
return to pre-operative doses as they recover and become more active.
The Radiology Department should be informed that the person has diabetes and of
their current medication.
Ensure the GP / MO has discussed the procedure with the person and obtained
consent (if applicable). Medication orders may be modified according to the type of
diabetes and medication, and the type and time of procedure. Reduction in dosages
requires discussion with the GP / MO and the person with diabetes.
Receiving insulin
If fasting, as per inpatient guidelines. Individual advice is essential based on type
of diabetes and insulin schedules.
Blood glucose should be checked before, during and after the procedure, if the person
feels unwell or complains of hypoglycaemic symptoms.
All people with diabetes should bring the following to the Radiology Department as a
precaution:
Special precautions may be necessary for people having any radio contrast study
(even using low ionic agents). This includes angiography, CT scan with enhancement
intravenous pyelography.
! impaired renal function creatinine clearance less than 30ml per minute.
In elderly people glomerular filtration rate (GFR) may be significantly reduced in
the presence of a marginally increased or normal plasma creatinine.
If radio contrast studies are necessary, the following precautions should be considered
by the GP / MO:
! stopping other medications several days before the procedure (eg diuretics, non-
steroidal anti-inflammatory drugs)
! hydration before, during and after the procedure using intravenous saline.
It may be necessary to reduce the dose of insulin if food intake is reduced. Discuss
medication adjustment with the GP / MO or diabetes educator.
Patient is eating
Diabetes target BGL
5-10mmol/L
EATING
3 regular meals
(NOT enteral or parenteral)
1. If BGL > than target for more than 24 hours 1. Increase patients usual
make incremental increases of OHA to the insulin dose (table 4)
maximum daily dose if required (table 1) OR 2. If BGL still not in target
2. Add supplementary insulin to OHA (table 2) within 24 hours use basal /
3. If BGL still above target use basal / bolus bolus insulin regimen
intensive insulin regimen (table 3) (table 3)
Patient fasting but will recommence oral diet within 6 hours after a procedure
Commence 5% glucose IV at
Withhold OHA on the morning 80-100ml/hr at 0600 or on
of the procedure (metformin admission to pre op area
48 hours prior)
Table 2
! Cease this additional dose of insulin when no longer required and/or prior to
discharge.
This is an intensive four times a day insulin regimen using short acting insulin with
each main meal and long acting analogue insulin at bed time.
Use approximately 2/3 of the total daily dose evenly split into 3 bolus doses; 1/3 of total
daily dose as basal bedtime dose
eg. 60kg patient - Total daily insulin dose calculated as 0.5units/kg/day = 30 units.
Split doses as:
Table 4
Breakfast 6 units NovoRapid
Lunch 6 units NovoRapid
Dinner 6 units NovoRapid
2100 12 units Glargine
OR
Patient previously on twice daily insulin of 40 units with breakfast and
25 units with dinner = 65 units daily.
Dose Adjustments:
Review patients 24 hour BGL profile each afternoon and adjust insulin orders
prospectively.
Adjust each dose up or down by 10% of current dose as required.
As the BGL at 0600 was high, the bedtime dose of Glargine is increased to prevent
the next mornings reading from being high again. As the patient had hypoglycaemic
episode at 1600, the lunch time insulin dose is reduced to prevent a similar occurrence
the next day. The other two doses (breakfast and dinner) were left unchanged as the
blood glucose responses to them (at 1100 and 2100) were in the target range.
The recommendations of NovoRapid has been made on the basis
of standardisation. Humalog and Apidra are considered clinically equivalent
and can be used as an alternative NovoRapid.
! Alter insulin dose to prevent prospective blood glucose rise or fall (eg. If the
before breakfast BGL is high then increase the bedtime basal insulin dose to
prevent the next morning reading being high).
Table 5
Sliding scale insulin for patients who are fasting - Subcutaneous only
! Check BGL 6 hourly (not QID: best timing is 0600, 1200, 1800, 2400hrs).
! Review patients BGL daily and increase insulin doses by 1 unit at each level
of the sliding scale if target BGL not achieved.
(The doses above may be used to determine a single stat dose of insulin when that
is required).
Hypoglycaemia
A `hypo kit and the hypoglycaemia protocol should be assembled and placed in a
prominent position in every health service, ward or clinical area. The following is an
example of a hypo kit:
It is recommended that hospitals and health services make a decision about which
glucose drink and which biscuit option to have in their hypo kit. The protocol on the
next page can be accessed in electronic format from the authors to enable modification
for an individual service.
Treatment of Hypoglycaemia
For patients on insulin or oral hypoglycaemia agents.
Indications: Blood Glucose Level (BGL) less than 4.0mmol/L irrespective of symptoms.
A Safe to Swallow Unsafe to swallow or Fasting Unconscious
EXAMPLE
must review and may give
IV glucose
Important points
! Document events and treatment given.
! Notify doctor.
! Observe pulse and blood pressure with event.
! Post glucagon vomiting is not uncommon.
Patients should be monitored more closely for the next 12-24 hours. The BGL frequency
will depend on the severity of the hypo as well as the persons individual risk factors. If
unsure, discuss with senior nursing staff or MO / GP. Observe person for at least 24
hours and blood glucose levels monitored 2 hourly if needed, up to 12-24 hours
depending on severity and duration of episode.
Note: some form of fast acting, rapidly absorbed carbohydrate should be left with
the person.
Preventing hypoglycaemia
Diagnosis
The process of HHS usually evolves over several days or weeks, whereas the evolution of
an acute DKA episode is much shorter. HHS only occurs in type 2 diabetes. 6 DKA is
associated with type 1 diabetes but has been known to occur in people with type 2
diabetes in the presence of an acute event such as septicaemia, respiratory collapse,
myocardial infarction etc. 7
Clinical presentation
For both DKA and HHS the clinical picture consists usually of polyuria, polydipisa,
polyphagia, weight loss, vomiting, abdominal pain (only in DKA), dehydration, weakness,
altered level of consciousness or mental status, and finally coma. Other physical findings
may be poor skin turgor, Kussmaul respirations (in DKA), tachycardia, hypotension,
alteration in mental status, shock and ultimately coma (more common in HHS).6
Nursing considerations
! Capillary blood glucose
! Blood or urine ketones
! Baseline observations
! Prep for IV cannulation
! Cardiac monitor
! O2 saturation
! Start fluid balance
! Ice chips or oral fluids if tolerated
! Consider in-dwelling catheter
Laboratory tests
! plasma glucose
! blood urea nitrogen / creatinine
! serum ketones
! electrolytes (with calculated anion gap)
! osmolality
! urinalysis
! urine ketones by dipstick
! arterial blood gases
! complete blood count
! ECG
! Bacterial cultures if infection suspected
! dehydration
! hyperglycaemia
! electrolyte imbalances, and
! the identification of co-morbid precipitating events and frequent patient monitoring is
crucial.
Fluid therapy
The initial fluid therapy is aimed at expansion of the intravascular volume and restoration
of renal perfusion. Subsequent choice for fluid replacement depends on the state of
hydration, serum electrolyte levels and urine output.6
Insulin therapy
Unless the DKA is mild, intravenous insulin infusion is required.
Potassium
Even though total body potassium may be depleted, mild to moderate hyperkalaemia is
not uncommon in patients with DKA or HHS. Insulin therapy, correction of acidosis, and
volume expansion decrease serum potassium concentration. Close monitoring of
potassium is needed to identify hypokalaemia. Replacement potassium may be needed.
Refer to your hospital clinical guidelines.
Bicarbonate
Severe acidosis in DKA can lead to a number of adverse vascular effects. The use of
bicarbonate in DKA will depend on the pH level.
Complications
The most common complications of DKA and HHS includes hypoglycaemia from over
administration of insulin, hypokalaemia due to insulin administration and treatment of
acidosis with bicarbonate and hyperglycaemia secondary to interruption / discontinuation
of IV insulin therapy without adequate cover from subcutaneous insulin. Cerebral oedema
is rare but when it occurs it is frequently fatal.6
If the person is unable to self manage the pump (eg simply too unwell, in pain, impaired
cognition or conscious state) it is recommended that the insulin pump is stopped and
replaced by an insulin infusion. The pump should not be removed until there is
another method of insulin replacement eg insulin infusion. If an insulin infusion is not
possible then multiple insulin injections will be required (long acting and short acting
insulin). Transition insulin dosing must be discussed with the patients endocrinologist.
If a patient is self managing the pump it is essential that nurses oversee and record blood
glucose results, insulin doses and carbohydrate (CHO) intake. This includes checking the
bolus doses with the patient before it is administered. Ensure accurate documentation at
all times.
Management of hypoglycaemia
If the person is conscious the hypo is treated as a person who does not have an insulin
pump (hypoglycaemia protocol figure 4). However if the BGL is less than 2.0mmol/L
then the pump must be suspended / disconnected and hypoglycaemia protocol followed
(figure 4). After 30 minutes of pump suspension and if the BGL is over 4mmol/L
recommence / connect the pump. If BGL remains less than 4mmol/L, contact MO as
person may need IV glucose.
Monitor
! Investigate cause.
! Document the event.
! After 30 minutes of pump suspension and if the BGL is over 4mmol/L recommence /
connect the pump. If BGL remains less than 4mmol/L, contact MO.
! It is necessary to review insulin administration rates to ensure that hypoglycaemia
does not recur and blood glucose level remains within target range.
Current guidelines for the management of hyperglycaemia recommend that the pump
should not be used to correct hyperglycaemia when ketones are present.9-11
If the blood glucose level is greater than 15mmol/L and there are ketones in the urine or
blood but the person does not have DKA the following principles apply.8, 9
! Immediately check for problems with the pump or delivery system and infusion site.
! Immediately contact the endocrinologist for instructions about insulin requirements
and need for insulin infusion.
! Give correction bolus via syringe.
! Replace the insulin in the pump, and the infusion set and re-site the cannula as
soon as possible.
! Recommence the insulin pump.
! Test the BGL hourly.
! Encourage the person to drink extra low joule fluids.
S/C: subcutaneous
IV: intravenous
Glossary
Basal insulin rate: refers to the continuous (24 hours a day) infusion of rapid acting
insulin. A persons basal rate is initially calculated using an algorithm by the diabetes
team but over time the person learns to adjust their basal rate as required. It is given as
units/hour eg 0.4/hr = 9.6 units over 24 hours.
Carbohydrate bolus: refers to the dose of rapid acting insulin that is administered using
the bolus feature of the pump when ingesting carbohydrates at meals / snacks. This is
calculated using an algorithm by the diabetes team. The carbohydrate bolus is given
immediately before eating or after eating eg 1 unit for 12 grams of carbohydrate.
Correction bolus: A correction bolus is an amount of insulin that is given to lower blood
glucose levels. A correction bolus is calculated using an algorithm based on the persons
insulin sensitivity factor. This calculation is usually different for everyone. This is
calculated using the bolus feature of the pump. eg 1 unit of insulin lowers the BGL by
2.4mmol/L.
A correction bolus may be given at any time but is often combined with the carbohydrate
bolus dose. For example if the BGL was 11mmol/L before meal then a correction bolus
would be needed as well a meal bolus otherwise BGL would still be high after eating.
1. What type of diabetes does the person have? (each type requires different treatment)
! type 1 ! type 2 % gestational ! secondary diabetes (eg steroid induced)
2. How do they manage/control their diabetes? (different treatment requires different self-care information):
b) Does the person understand what their treatment regime is? (eg time to administer, side effects, dose. If
they are on insulin is the administration technique correct? (Refer to Section 10 in Diabetes Manual)
! yes ! no (please teach) ! carer/nursing home/hostel provides care
c) If on sulphonylureas or insulin is the person aware of risk for hypoglycaemia and how they should prevent and
manage it if it occurs?
! yes ! no (please teach) ! carer/nursing home/hostel provides care
3. a) Does the person monitor their BGLs (blood glucose levels)? (it is highly recommended that persons on
sulphonylureas or insulin test their BGLs regularly due to potential for hypoglycaemia)
! yes method __________________ any problems _____________________ ! supplies (NDSS or Chemist)
! no - person states they do not wish to test (ensure they are aware of signs/symptoms of
hyper/hypoglycaemia)
- diet, metformin or arcabose only (ensure they are aware of signs and symptoms of hyperglycaemia)
! other nursing home or hostel nursing staff are performing the test
b) If the person has type 1 diabetes are they aware of the procedure and action with ketone testing if their
BGLs are above 15mmol/L and / or they are unwell? (Sick day management)
! yes ! no (please teach) !not applicable ! care/nursing home/hostel provides care
1. Does the person understand the role of a healthy eating plan in diabetes management?
! yes ! no (please teach) ! care/nursing home/hostel provides care
2. Is the person aware of the need for regular checks by LMO or diabetes specialist? (see over page).
Refer to Long-term Management leaflet.
! yes ! no (recommend visit to LMO after discharge for regular review)
3. Is there an active foot problem at the moment? (eg callouses, corns, ingrown toenail, infection, signs of
pressure or neuropathy or ulcers) see Section 6, Diabetes Manual.
! yes (refer for foot risk assessment )
! Type 1: occurs as a result of insulin deficiency following autoimmune destruction of pancreatic beta cells.
Dependant on insulin for survival from diagnosis.
! Type 2: characterised by insulin resistance and insulin deficiency. Usually occurs in people over 40 years. Initially
controlled by healthy eating, exercise, and OHAs. May eventually need insulin to assist in management.
! Gestational: diabetes detected during pregnancy.
! Secondary: examples include disorders with pancreatic pathology, use of medications (glucocorticoids), liver disease
and other endocrine disorders.
MEDICATION ADMINISTRATION (It is a nurses duty of care to ensure the following is taught prior to discharge)
! Action, side effects, timing, dose, availability of medication (eg chemist with script from LMO).
! Insulin: correct technique, correct timing, correct dose and site. Observe and document administration technique.
MONITORING
DIABETES ASSESSMEN T.Page 2
! Times to test: before a meal is preferred so that medication can be adjusted accordingly.
! Frequency of testing: depends on their control and how stable.
! Supplies: National Diabetes Supply Scheme is the most cost effective (Diabetes South Australia U4/159 Sir
Donald Bradman Drive, Hilton Ph 8234 1977).
! Sharps disposal: sealable hard plastic container or with sharps container through councils. Sharps must not be
thrown in the bin, as household rubbish becomes landfill.
! Quality control meter: recommended monthly with control solutions.
EMERGENCIES (It is a nurses duty of care to ensure the following is taught prior to discharge)
Hypoglycaemia
Hyperglycaemia
! Symptoms: thirst, lethargy, polyuria, weight loss, blurred vision, recurrent infection.
! Causes: stress, illness, infection, not enough medication, too much carbohydrate.
! During illness medication should not be stopped as insulin requirements generally go up.
! Symptomatic hyperglycaemia should seek medical advice as soon as possible.
HEALTHY EATING
! Encourage regular meals with even distribution of carbohydrates throughout the day.
! Low fat, high fibre and limiting quickly absorbed carbohydrates.
! Importance of regular GP reviews (3-6 monthly) and within one week of discharge from hospital.
! A measure of HbA1c (average blood glucose level) recommended 3-6 monthly.
! 2 yearly eye checks (more frequently if problems stated), yearly kidney checks, regular BP, cardiovascular, nervous
system and cholesterol level checks.
! Regular flu and pneumonia vaccinations.
! Footcare: daily inspection, treat problems early, avoid excessive heat or cold. Encourage appropriate footwear.
Cut nails following the normal contour of the toe, file sharp edges. See podiatrist if problems occur.
7. Dunning T (2009) Care of people with diabetes. John Wiley and Sons Ltd,
United Kingdom.
11. New South Wales Insulin Pump Interest Group (2006) Insulin pump therapy: An
information booklet for diabetes health professionals interested in establishing
an insulin pump therapy service, Diabetes Australia & ADEA, Canberra.
Although glucose can be measured in both blood and urine, blood glucose
measurement is preferable for the following reasons:
! blood glucose measurement gives more accurate information about the present
state of the blood glucose
! urine glucose is variable due to changes in renal threshold, therefore blood
glucose levels are usually not less than 10mmol/L before they register in the urine
! urine glucose monitoring cannot detect hypoglycaemia.
All methods are potentially inaccurate and the reliability of any test also depends
upon the quality of the equipment, basic quality assurance (QA) systems and the
skill and experience of the person performing the test. Only staff trained and
competent in the use of blood glucose meters for blood glucose monitoring
should perform the tests.
People with diabetes should be encouraged to perform their own blood glucose
monitoring if they have access to a meter they can use at home. A health professional
trained and accredited in meter operation should assess the persons technique before
they perform their own tests in hospital. However, due to the increasing numbers of
meters and various techniques, hospital staff may not be familiar with the persons
particular meter. Meter company representatives can provide information to assist.
Remember
Many factors may affect the accuracy of test results. Strategies for reliable blood
glucose measurements include:
Blood glucose measurements with hospital meters can only be performed by staff with
current accreditation. Information is available from your diabetes educator or meter
company representative about quality assurance programs.
Universal precautions
Follow universal precautions for all blood glucose monitoring. Remember when
handling body fluids, treat all fluids as potentially infective. Ensure that blood testing
technique does not increase the risk of infection from blood products.
3. Dispose of all materials that have been contaminated with blood immediately.
5. When teaching, ensure personal lancing device is always left unloaded (dispose
of used lancet immediately after use).
6. Professional use lancing devices must be disposable, single use and have
retractable lancet.
8. Ensure work area and surfaces are cleaned and all traces of blood removed.
Hospital blood glucose monitoring must be accurate and reliable to guide management
decisions. A hospital accreditation program is essential to ensure accuracy and to
maintain ongoing review of blood glucose monitoring techniques / results performed by
staff.
To ensure that each operator is competent in using a blood glucose meter, we need a
method of checking that the equipment and operator performance meet pre-set
standards. This is achieved through the implementation of a quality assurance
program.
Accuracy: agreement between result obtained for the sample and its true value.
Acceptability: when a test result lies within acceptable intervals (usually + or - 10% of
true value).
Blood glucose meters can only be used by staff members who have successfully
completed an annual meter education and accreditation program.
Staff cannot operate blood glucose meters if accreditation status has lapsed.
! Every 24 hours
! Each time a new bottle of strips is opened
! If the meter is dropped
! When the batteries are changed
! If the BGL is questionable.
Quality control solutions are available for each type of meter and they contain a set
amount of glucose. The test result must be within the range specified for the meter and
strips being used. The test should be documented and records of quality control
records should be kept for 7 years.3
2. Detailed functions.
Learner participation
Under supervision all participants will have the opportunity to practise reagent strip
control checks, blood glucose measurement and cleaning the instrument.
Evaluation method
Accreditation
Staff should be accredited after successful completion of the program and evaluation
procedures.
Program evaluation
Annual re-accreditation
Re-accreditation of technique should occur annually. An audit process can be used for
review of procedure and technique (Appendix 1).
Consult with your regional diabetes educator. In most cases this person is accredited
to conduct accreditation activities. Otherwise, hospital staff can be accredited directly
by meter company representatives. An example of an accreditation tool can be seen in
Appendix 2.
Values at two hours post-prandial would reflect peak glycaemia which is affected by
factors such as the food eaten, gastric emptying, insulin resistance, medications and
illness.
! Type 1 diabetes.
! A1c being lower or higher than expected from the existing blood glucose profile
(because of possible hidden hypo or hyperglycaemia).
! Unstable blood glucose, particularly those tending to hypoglycaemia before the
next meal.
! Hypoglycaemia, particularly in those with hypoglycaemic unawareness.
The appropriate times to test will vary with each individual and will often be the result of
a joint decision of the individual and their general practitioner / medical officer /
diabetes educator.
Times
Samples
Whole Blood - has 10-15% lower glucose values than plasma because the
sample contains blood cells which have low glucose levels
- capillary whole blood samples are taken for ward or self blood
glucose monitoring tests.
Summary
Strategies that can be used to enhance the effectiveness of SMBG include the
following.8(p1012)
! Stress the importance of SBGM as data needed by the person for decision
making, not as something done primarily for the benefit of the provider.
! Emphasise that the results are not a judgment of the persons self-management
efforts but simply a number they can use to make informed decisions.
! Assist the person to identify blood glucose targets and actions to take to achieve
those targets.
! Identify strategies for overcoming barriers to monitoring.
! Assist the person in dealing with the impact of results.
! Help the person to identify strategies to obtain the support they need for SBGM
from members of their families and health care team.
! Role-play responses to negative comments about the results from members of
their family and health care team.
2. Self blood glucose monitoring should be used in the management of all pregnant
women with diabetes and all people on insulin therapy.
4. People who are diet controlled or on metformin alone can be provided with the
option of blood glucose monitoring. If they choose not to self monitor then it is
important that they are informed of the need for 3 monthly HbA1c tests as this will
be the only measure of control.
5. Quality control solutions are recommended for use by people who self monitor
with a meter, to ensure reliable and accurate results. Support and resources
must be provided to encourage the person to maintain monitoring standards.
Alternatively people may be able to go to their local Diabetes Service Pharmacy
or Diabetes Australia to have their meter quality control checked.
7. It is important to ensure that the person has the correct technique when using
their meter and that the meter is providing accurate results.
When to test
The targets and frequency of testing will depend on what type of diabetes the person
has, the type of treatment they are on (diet, tablets or insulin) and the intensity of their
regimen. For example a person who is on a basal bolus regimen (4 injections a day)
will need to test at least 3 - 4 times a day whereas a person who is only having a basal
insulin regimen (1 to 2 injections) will be able to test less often. People need to be able
to adjust the times and frequency based on their current situation.
! Monitoring is only meaningful if the person knows what the target is.
! Monitoring is only useful as a self management tool if people can interpret their
results and work out what has caused high / low BGLs so they can take remedial
action to bring BGLs back into target.
! The person needs to understand that how they feel is not an accurate estimate of
BG levels and not good enough evidence on which to base self management
decisions.
! Any self monitoring must be meaningful to the person doing it that is they are
doing it for a reason or to find out the effect of their diabetes management (food,
activity, medication) and make management decisions.
! Reassure that out of target BG levels are manageable even if it takes a while
to figure out what to do.
A regular monitoring schedule for glycated proteins provides information which helps to
assess overall control.
The test can be done every 3-6 months to check overall control.
Ketones can indicate impending acidosis. Ensure the medical officer is notified if
ketones are detected in urine or blood.
For more information about the monitoring of ketones and its role in sick day
management see Unstable Diabetes Section 11 or www.adea.com.au.
Note: Ketone testing is only routinely performed if the person has type 1 diabetes.
Microalbumin
Proteinuria is the hallmark of diabetic nephropathy. The appearance of proteinuria
during the routine review of people with diabetes is common. The time of onset of
proteinuria and the rate of increase is variable. However, once clinical proteinuria
occurs (dip stick positive, >500mg/L) progressive renal damage is likely 11. Initially
intermittent low grade proteinuria occurs (microalbuminuria, 20-200#g/min). A
laboratory microalbuminuria test is recommended to detect early changes in renal
function. Evidence of microalbuminuria usually precedes the macro proteinuria that is
detected with dipstick methods. Microalbuminuria can also be detected using Micral-
Test$. This strip test can be used outside the central laboratory and is an
immunological reagent carrier as opposed to a chemical dipstick. It uses a monoclonal
antibody test to give a semi quantitative measurement in the range 0-100mg/L of
albumin in urine.
People with diabetes may develop overt clinical manifestations of renal disease,
generally termed nephropathy. Eventually a proportion of these people will either
require dialysis or kidney transplantation. Microalbumin is also an indicator of blood
vessel disease and therefore a marker for cardiovascular disease.
Monitoring people with diabetes for microalbuminuria is therefore important if a
protocol is to be implemented which can detect and possibly reverse ultimate
renal damage or cardiovascular disease.
Assessment
! Test for microalbuminuria. This can be done using a first morning voided spot
urine or an overnight collection.
! Test urine with multistick to ensure the absence of infection. Infections will
reduce the reliability of the result. Retest once the condition has improved.
! If microalbuminuria present, perform up to two additional measurements in the
next 6 weeks. Diagnosis of microalbuminuria is established if 2 of the 3
measurements are abnormal.
Interpretation of results9
Category Timed Urine Sample First Morning Sample
Albumin (ug/min) Albumin: Creatinine
Ratio
Female Male
Normal <20 0-3.5 0-2.5
Microalbuminuria 20-200 3.6-35 2.6-25
Macroalbuminuria >200 >35 >25
What to do
If macroalbuminuria:
Name:
1. wash hands ! !
2. ensure all equipment is available ! !
3. confirm meter cleanliness and function
(date and time) ! !
4. confirm meter is correctly calibrated ! !
5. ensure strips have not expired/deteriorated ! !
6. perform control test ! !
7. identify the person correctly ! !
8. give clear and relevant explanation to the person ! !
9. advise the person of possible discomfort ! !
10. put on gloves when appropriate ! !
11. ensure patients skin area is clean ! !
12. correctly prepare finger pricking device
using aseptic technique ! !
13. correctly choose site for blood sample ! !
14. correctly load strip into meter (if appropriate) ! !
15. correctly commence meter operation (as appropriate) ! !
16. correctly prick finger (use side of finger, not tip) ! !
17. correctly obtain a drop of blood ! !
18. correctly ensure accurate timing (if appropriate) ! !
19. correctly read test result ! !
20. correctly record result on blood glucose monitoring
record ! !
21. correctly interpret result and take appropriate action ! !
22. terminate the procedure suitably ! !
23. clean, replace, dispose of equipment appropriately ! !
24. wash hands ! !
Comments:
OBJECTIVE: The Registered/Enrolled nurse will be able to demonstrate the use and
maintenance of the hospital nominated blood glucose meter, according to listed criteria.
Comments: ______________________________________________________________________
_____________________________________________________________________
References
1. The Queen Elizabeth Hospital (2008) Infection prevention & control &
community based care. The Queen Elizabeth Hospital, Adelaide.
2. Royal Adelaide Hospital, Modbury Hospital, The Queen Elizabeth Hospital, and
Repatriation General Hospital (2009) Quality assurance for blood glucose
meters: Personal communication. Diabetes Outreach, Adelaide.
10. Australian Diabetes Educator Association (2006) Guidelines for sick day
management for people with diabetes, ADEA, Canberra.
The effects of diabetes and complications of diabetes commonly target the feet. Any
person with diabetes, of whatever age, requires good foot care whether at home, in
hospital or in a nursing home. The feet of a person with diabetes are at risk of damage
due to a combination of small and large vessel disease, nerve damage and mechanical
instabilities in the foot.
Diabetic foot ulcers usually occur as a result of two or more risk factors occurring
together. In particular peripheral neuropathy plays a central role. Statistics show that
anywhere from 19.6%2 and 50%1 of people have at risk feet. All health care providers
can play a role in helping people assess their own level of risk and to understand their
own self care practices.
Poor glycaemic control increases the risk of vascular disease, neuropathy and
infection.3 Hyperglycaemia may lower immune response, increase the risk of infection
and delay healing.
Neuropathy
Peripheral neuropathy, with or without peripheral vascular disease is a major
underlying risk factor in people with diabetes developing a foot ulcer.3 Sensory loss
associated with peripheral neuropathy becomes progressively more common with
increasing duration of diabetes. Neuropathy leads to an insensitive foot. Neuropathy
also sometimes leads to a deformed foot which then causes more pressure on different
parts of the foot, resulting in thickened callus or corns and potential ulcers. If a person
with neuropathy has a minor trauma such as blisters (from ill fitting shoes or walking
barefoot on hot ground) this can be enough to start a chronic ulcer.1 If the person
cannot feel that they have an injury then they will continue to re-injure the area and will
not identify the need to seek help.
Foot deformity
Foot deformities such as bunions, hammer or claw toes, callus and Charcot foot are
major contributors to increasing foot pressures. Callus develops in response to shear
stresses and usually occur close to a bony prominence. Callus contributes to
increases in foot pressures by acting as a foreign body and predisposes to the
formation of ulcers beneath these lesions.3 Limited joint mobility and bony deformities
or callus in the presence of neuropathy increases the risk of ulceration.3 Similarly
deformity from previous amputation also increases the risk of ulceration (3-fold
increase).
NHMRC guidelines suggest that people with diabetes need regular assessment to
detect foot deformities.3
All health care providers should be involved in ensuring that the person with diabetes
has regular inspection and examination of both feet. This involves assessing the
person in a standing and sitting / lying position with their shoes on initially and then
without their shoes. Shoes and socks should be also be inspected. It is through
regular checks and reinforcement of appropriate and relevant self care practices that
the person with diabetes will have a solid understanding of the importance of foot care.
A key aspect of education is to teach those with at risk feet the importance of self care.
The responsibility of the individual with diabetes or of their carer cannot be emphasised
strongly enough. Daily inspections of at risk feet and footwear should be conducted at
home, with particular attention paid to the identification of any problems and early
management of these.
Identifying the foot at risk can be based on the National Association of Diabetes
Centres (NADC) 2004 Basic Foot Screening Checklist (Appendix 1). The checklist is
broken up into 7 sections which will be discussed in more detail below.6
Note:
The NHMRC guidelines Diabetes foot problems adopts the following definitions to
describe risk categories for diabetes foot problems:
! high risk people foot deformity with neuropathy or peripheral vascular disease
or previous ulcer or previous amputation.3
Section 1
Ask the person if they have experienced previous foot problems, symptoms of
neuropathy or intermittent claudication. Ask about previous foot ulcer or amputation
because this will immediately put the person in an at risk category for another ulcer.3
Mechanical factors are those related to structural changes, the shape of the foot and
the type of footwear. Small muscle wasting, secondary to neuropathy may develop in
the feet leading to an abnormal posture of the foot. It may be difficult to find a
comfortable, well-fitting shoe.
Assessment of mechanical factors includes observation of gait and shoe wear pattern.
Gait problems may indicate special footwear is necessary. Conditions include hammer
toes, clawfoot, bunions, calluses, partially amputated feet, Charcot feet and other
deformities.
Section 4
Test both feet for neuropathy
The NHMRC footcare guidelines recommend that all people with diabetes be routinely
assessed with a 10g monofilament to detect loss of protective foot sensation (see
Appendix 2 for instructions).3 The 10g monofilament is clinically reliable and best
practice. However, if this is not available cottonwool can be used in the same way
(note this method is not gold standard). These tests measure nerve supply to the feet
and the persons ability to detect injury to the feet. They are testing for loss of
protective sensation.
There is limited data to support which sites should be tested using the monofilament.
The NHMRC guidelines suggest that testing at two sites (over the first and fifth
metatarsal heads) is sufficient to identify loss of protective sensation.3
Section 5
Assess footwear
Ensure footwear is of appropriate size, shape and width to accommodate the foot.
Avoid vinyl uppers as these can trap moisture. Poorly fitting shoes can cause blisters
and corns which may ulcerate, especially in the person with sensory loss.6
Section 6
Assess education need
As part of the foot assessment it is important to ascertain what the person understands
about the effects of diabetes on foot health. Asking the person do they know why and
how diabetes can affect their feet and what the associated self care practices are. Are
their feet adequately cared for.
Section 7
Assess self care capacity
The last part of the assessment is an opportunity to assess whether the person is
capable of the level of care that is required for their level of foot risk.
At the end of the assessment it is important to document whether or not the foot is at
risk. Using the NADC Action Plan in Appendix 3 can be a useful tool for documenting
your findings and plan. The person is deemed to be at risk if they have any history of
ulceration or amputation, neuropathy, PVD, foot deformity or any other abnormality that
was identified during the assessment.
If the foot is deemed to be at risk then further referrals will need to be arranged. The
type and urgency of the referral will depend on the problem identified for example;
! reduced circulation poor colour, cooler to touch, reduced or absent pulses (if
foot is cold, pallor and pulses are absent consult a general practitioner or medical
officer)
! nerve damage numb feet, reduced sensation
! abnormal nails thickened, ingrown
! abnormal foot structure, bunions, hammer toes
! evidence of trauma calluses, past ulcers.
Further referral to a vascular surgeon may also be necessary for circulatory problems.
Health care providers should assist as appropriate for those who are not able to
manage themselves.
! Moist skin - Commonly found inter-digitally, especially when toe joints are
stiffened. Refresh toe creases with methylated spirits or Povidone-iodine solution
on a cotton bud. It may be necessary to use a tinea solution.
! Minor skin damage - Treated by using the recommended first aid routine below.
First aid for minor skin injuries (small cuts, abrasions etc)
Wash the feet, ensure a seat in a good light and provide a pair of clean, stainless steel
nail clippers. Each person must have their own clippers or clippers need to be cleaned
and sterilised between cuttings.
Trim nails following the natural curve of the toe, being sure not to cut too short. Never
cut down the sides of the nail. If there are sharp edges, file with nail file or emery
board.
! daily inspection of feet, including areas between the toes (if not possible then
arrangements will need to be made for someone else to be able to do it)
! regular washing of feet with careful drying, especially between the toes (water
temperature always below 37 degrees)
! do not use a heater or a hot water to warm up feet
! avoid walking barefoot when walking indoors or outdoors
! avoid wearing shoes without socks
! daily inspection and palpitation of the inside of the shoes
! do not wear tight shoes or shoes with rough edges and uneven seams
! do not use moisturising creams between the toes
! change socks daily
! wear stockings inside out or seamless
! do not wear tight or knee high socks
! care in cutting nails (see diagram)
! always have corns and calluses removed by a podiatrist
! notify healthcare provider at once if blister, cut, scratch or sore has developed
(action plan)
! ensure regular examinations by podiatrist and other health professionals.
Someone with diabetes and normal sensation, circulation and structure needs the
same foot care and footwear as someone without diabetes.5 However all people with
diabetes need to be well informed about the potential for future problems and the
importance of early diagnosis ie the need for 6 monthly foot checks by their GP,
diabetes educator or podiatrist.
For those people who have one or more risk factors it is recommended that they have
an up to date action plan developed as part of the education process. The action plan
can be used as a tool to link their risk status with self care practices (see Table 1).
EG Scenario: 55 year old man with neuropathy but who has good blood supply and
no visual impairment or musculoskeletal problems. See table below.
Cut or abrasion skin break Make sure shoes are worn at all times to protect
your feet from damage.
If damage occurs:
Pressure areas excess pressure Check feet daily to see if there area any signs of
pressure or other damage.
eg redness,
blisters Break shoes in slowly.
eg Redness,
warmth or
swelling
Callus and corns are signs of pressure and the mainstay of treatment is to reduce the
pressure to prevent recurrence.
Corns and calluses should never be cut or removed with commercial remedies which
may ulcerate the skin. Refer to podiatrist.
6. Education of patient and relatives eg self care, how to recognise and report
(worsening) signs and symptoms of infection such as fever, changes in wound or
hyperglycaemia.
Keep feet warm. A cold foot will automatically close down peripheral circulation. An
ischaemic area, under pressure, may precipitate skin breakdown and subsequent
ulcer. Use cotton or wool socks and sockettes to increase warmth.
Use cushioning materials, attend pressure areas two hourly with immobilised,
paralysed or unconscious patients, keep the feet warm with socks, wash and
thoroughly dry interdigital areas and treat macerated skin.
Lengthy bed rest often associated with hospital admissions requires careful
assessment and daily observation of feet. Avoid pressure being exerted on toes and
heels.
Education of the person in the care of their own feet is of prime importance.
Assistance from family or friends is essential where the person has difficulty seeing or
reaching the feet. The older person may require assistance.
Encourage the person to carry out self care as stated in the foot care section on the
previous page.
The need for keeping blood glucose as close to normal as possible needs to be
reinforced to the person.
Smoking, high alcohol intake, excess weight should be reduced as part of prevention.
DATE _______/____/______
LEFT RIGHT
3. Check foot Dorsalis pedis Y N Y N
pulses
Posterior tibial Y N Y N
LEFT RIGHT
4. Test for Monofilament Y N Y N
neuropathy detected at sites
marked - o
All people with diabetes need to have their feet screened with these 7 simple steps
every 12 months or more often if problems are identified
! Test first at a site with normal sensation - away from feet (eg. hands)
! Do not allow the monofilament to slide across the skin or make repetitive contact at
the test site
! Ensure person has their eyes closed while you do the test
! Avoid testing areas where there is callus, scar, neucrotic tissue or ulcer
! Press the filament to the skin and ask the person whether he/she feels pressure
(yes/no) and then ask where they can feel the pressure (left foot / right foot).1
! Protective sensation is present at each site if the person correctly answers 2 out of
3 checks 1
! If the person gives 2 out of 3 incorrect answers their protective sensation is absent
and they are considered to be at risk of ulceration 1
A B
PATIENT NAME
Action*
Record details of personnel referred to. Where resources are unavailable, indicate
and describe alternative care provision
3. National Health & Medical Research Council (2005) Part 6: Detection and
prevention of foot problems in type 2 diabetes. March, NHMRC, Canberra.
1. People living outside the metropolitan areas have higher rates of mortality and
morbidity than people living in metropolitan areas.2
2. Recruitment and retention are problematic for those health professionals with
specialist skills.3
! In 2007, SA had 82,500 adults (age 16 years and over) living with diabetes in
country areas.4
! Comparisons done between metropolitan Adelaide and country SA in 2005 found
the prevalence of diabetes to be significantly higher in country areas 10.2%
compared to 7.8%, a 2.4% difference.5
! There are 191 children living in country areas who have type 1 diabetes, 29 of
these are on insulin pump therapy.6
! There are 127 young adults between the age of 18 and 25 with type 1 diabetes
living in country SA, with 64 of these on insulin pump therapy.6
! 44% of people with diabetes in SA have high cholesterol levels.7
! Persons living in rural and remote regions generally have worse health, in terms
of mortality, hospitalisation rates and risk factors compared to those living in
metropolitan areas.8
Caring for people in a rural or remote setting brings with it all the challenges of
distance, isolation and limited access to specialist support services. Strategies such as
developing networks at a local, regional and state-wide level can help to overcome
some of the barriers.
Major rural centres generally have a core range of health professionals eg diabetes
educators, dietitian, podiatrist, physiotherapist, optometrist or ophthalmologist. For
health professionals working in smaller health services within a larger cluster of health
services, virtual teams can be set up to facilitate access to specialist support and
information / education for people with diabetes in their communities.
Rural and remote areas are home to people with all types of diabetes. It is important
that diabetes services in rural and remote areas are cognisant of the fact that they play
an important role in providing and facilitating best practice in diabetes education.
For example, in a rural area there may be people with type 1 diabetes, children and
adolescents with type 1 diabetes and at times some with type 2 diabetes. The
geographical area may also have women with gestational diabetes and women with
pre-existing type 1 or type 2 diabetes who are pregnant. It is important that education
services do not ignore the education and support needs of these groups. If education
services do not have the expertise to provide education in these areas it is essential
that the service facilitate access in some way (eg distance technologies) to ensure
access to education and support for all people living with diabetes in rural and remote
areas.
Many of the complications from diabetes can be prevented with the appropriate
community based primary health care interventions.13 Structured approaches are
needed if outcomes of Indigenous Australians are to be improved. A structured
approach consists of a shift from reactive care to proactive care. Aboriginal health
services require systems of care which ensure early detection and care planning with
clients. Registers and recall systems which are linked to appropriate action are integral
to this process.13
In Australia, State funded health services provide services to the whole community. In
some areas the Aboriginal Community Controlled Health Services (ACCHS) are also
providing primary health care services specific to Indigenous communities. Which ever
service is available, it is essential that regional and ACCHS work together to ensure
access and equity of service.
The roles of Aboriginal Health Workers (AHWs) within the community health teams of
both state funded services and Aboriginal Community Controlled Health services is
integral when working with Aboriginal people with diabetes. Some AHWs are also
trained as diabetes educators and should provide the majority of education and
support. AHWs assist with providing culturally appropriate care.
There are many resources available which are specific to Indigenous communities.
! Diabetes Australia Northern Territory
www.healthylivingnt.org.au
! Diabetes Australia Victoria
www.diabetesvic.org.au
! Diabetes Australia New South Wales
www.diabetesnsw.com.au/about_diabetes/indigenous_introduction.asp
! Australian Indigenous Health Information Net
www.healthinfonet.ecu.edu.au/chronic-conditions/diabetes
As people migrate to a country like Australia (western culture) they may start to adopt
some of the lifestyle behaviours eg eating a greater proportion of high-energy dense
foods or reducing exercise levels. Such changes can lead to excess weight gain, thus
increasing their risk for type 2 diabetes.15 Furthermore research highlights that
migrants are at a high risk of diabetes complications due to the many barriers that they
face when accessing health services. Barriers include:16
! language
! literacy (in English and native language)
! stigmatisation
! lack of access to culturally specific care
! religious beliefs and cultural practices.
It is important to recognise that religious beliefs and / or cultural practices can affect the
persons ability or desire to self manage. There may be different perceptions of what
actions will have a positive effect on health across various cultures.
! culturally specific
! incorporate the diet, beliefs and attitudes of the cultural group
! foster increased understanding, interest and participation.
Health professionals need to be aware of special circumstances that could be a risk for
the client eg Muslims wishing to fast during Ramadan. Health professionals will need
to work with clients to ensure that safety is maintained during this period.17, 18
Culturally specific resources can help with these situations and Diabetes Australia does
provide a national Multilingual Internet Resource for consumers and health
professionals.19
Current guidelines recommend that children and adolescents should have access to
care by a multidisciplinary team trained in childhood and adolescent diabetes.21 In
rural and remote areas the local team should work in a shared care arrangement with
the appropriate tertiary level diabetes service.
Children
Children with type 1 diabetes require insulin from diagnosis and insulin requirements
will change as they grow into adulthood. It is becoming more common for children to
be on an insulin pump or on multiple dose injections (MDI) from a very young age.
Adolescence
The management of diabetes during adolescence can be difficult for a myriad of
reasons. Firstly, puberty is associated with insulin resistance and so many young
people require more insulin than what is usually needed for their weight. Other issues
such as alcohol and illicit drug use, dating, sex, contraception, driving, employment,
study and sport must be discussed in a non judgmental way.
All children and adolescents in school or child care must have a care plan that has
been developed in consultation with the paediatric service, parents and school staff.
For more information, visit www.decs.sa.gov.au (Department of Education and
Childrens Services).
Young people with diabetes need support to stay connected to their diabetes health
professionals. Resources such as www.realitycheck.org.au can be invaluable for
young people as the website is written by young adults who have type 1 diabetes. The
website has many stories and real life accounts of what it is like to live with type 1
diabetes 24/7.
There is also a possibility of diabetic ketoacidosis in clients taking SGA medication and
clients need to be assessed for and aware of the signs and symptoms of
hyperglycaemia.26
Health professionals who care for clients with mental illness should encourage healthy
nutrition and activity as these can improve metabolic parameters even when there is no
weight loss.23
3. Lowe S and O'Kane A (2003) Workforce report for South Australia. Services for
Australian Rural and Remote Allied Health Inc, Canberra.
5. Population Research & Outcomes Studies Unit (2006) Diabetes in rural and
metropolitan areas. DiabInfo. July, Government of South Australia, Adelaide.
8. Australian Institute of Health and Welfare (2006) Rural, regional and remote
health - Mortality trends 1992-2003. AIHW Cat. No. PHE71, Australian Institute
of Health and Welfare, Canberra.
11. SA Health (2008) South Australia: Our health and health services. Government
of South Australia, Adelaide.
12. Australian Bureau of Statistics and Australian Institute of Health and Welfare
(2008) The health and welfare of Australia's Aboriginal and Torres Strait
Islander peoples. ABS Catalogue No. 4704.0, AIHW Catalogue No. IHW 21,
Commonwealth of Australia, Canberra.
15. Thow A and Waters A (2005) Diabetes in culturally and linguistically diverse
Australians. Australian Institute of Health and Welfare, Canberra.
SECTION 7 COMMUNITY GROUPS WITH SPECIAL NEEDS REVISED SEPTEMBER 2009
6
16. von Hofe B, Thomas M, and Coligiuri R (2002) A systematic review of issues
impacting on health care for culturally diverse groups using diabetes as a
model. Australian Centre for Diabetes Strategies & Multicultural Health Unit,
Sydney.
17. Burden M (2001) Culturally sensitive care: Managing diabetes during Ramadan.
British Journal of Community Nursing, 6(11): p581-585.
18. Naeem A (2003) The role of culture and religion in the management of
diabetes: a study of Kashmiri men in Leeds. The Journal of The Royal Society
for the Promotion of Health, 123(2): p110-116.
20. Australian Institute of Health and Welfare (2008) Incidence of type 1 diabetes in
Australia 20002006. Australian Government, Canberra Cat. no. CVD 42.
! To address individual nutrition needs, taking into account personal and cultural
preferences and willingness to change.
! To maintain the pleasure of eating by only limiting food choices when indicated
by scientific evidence.
Purpose of kit
1. To provide a means of making a preliminary dietary assessment.
2. To provide initial dietary advice, to help the person start making necessary
changes in their diet prior to more `in depth dietary education later.
3. To promote continuity of dietary education between doctor, diabetes educator
and dietitian.
This kit, in conjunction with the Diabetes Manual, will assist in providing information for
nutrition education and can be obtained from The Queen Elizabeth Hospital Diabetes
Centre. Further information may be required for people with type 1 diabetes.
All people with newly diagnosed diabetes should have access to dietary education
preferably with a dietitian. If resources for dietetic services are limited then the
following client groups should take priority in seeing a dietitian:
Waist circumference measurements are another useful tool for assessing risk of
chronic disease. Excess weight around the waist / abdomen is associated with
insulin resistance and a higher risk for chronic disease. A waist measurement
of greater than 94cm for men or 80cm for women is an indicator of the internal
fat deposits, which coat the heart, kidneys, liver and pancreas. Measurements
of more than 102cms for men and 88cm for women greatly increase the risk of
chronic disease.
*
Body Mass Index (BMI) is calculated as weight (kg) divided by height (m)2. Ideal range =
2024.9kgm2; underweight = <20kgm2; overweight = 2529.9kgm2; obese class 1 = 30
34.9kgm2; obese class 2 = 35 39.9kgm2; obese class 3 >40kgm2.
Carbohydrate foods that can assist in improving blood glucose levels are those
that are low in fat, high in fibre and are broken down slowly to glucose (low
Glycaemic Index, GI). Examples of such foods are wholegrain breads and
cereals, legumes (eg baked beans), most fruit, low fat milk and low fat yoghurt.
See next section for more information on GI.
! they can assist with the management of diabetes as they may produce
lower blood glucose levels
! they can help to improve satiety (ie make you feel fuller for longer) thereby
assisting in appetite control
! they may help to reduce the incidence of hypoglycaemia for those on
insulin or sulphonylurea medications.
! the overall nutrient content of the food, especially the fat content of foods
(eg chocolate has a low GI but is high in fat)
! the amount of food eaten (eg a large amount of food that is low in GI will
still likely have a large impact on BGLs).
At least one low GI food per meal is recommended. See table 1.
Juices
Fruit juices (apple, orange,
pineapple, grapefruit)
* These are foods high in fat. Use them occasionally.
Australians consume too much fat with many having over 40% of total energy
intake. An intake of 30% or less is recommended, with a focus on lowering
saturated fat intake.
Saturated fat is often referred to as the bad fat as it raises blood LDL
cholesterol levels. Saturated fat mainly comes from animal products and some
plant oils (mainly palm and coconut oil) (refer to table below). Unsaturated fats
(either poly or mono-unsaturated) are known as good fats as they may help to
improve blood cholesterol levels if they replace saturated fats in the diet.
Fat on meat, chicken skin, fatty meats - eg Trim fat from meat, remove chicken skin,
sausages, fritz, bacon, salami, deep-fried use lean cuts of meat, cook without fat or
foods, pies, pasties. use an oil spray.
Snack foods - eg nuts, crisps, hot chips, Limit quantity of snacks. Try crisp, raw
prawn crackers. vegetables, fruit, pretzels, or plain popcorn
instead.
Large amounts of margarine, butter, oil, Limit to 1 tablespoon per day of added fats,
cream, peanut butter, dripping, lard, ghee, preferably poly or monounsaturated
coconut cream. margarine or oil.
Full fat (regular) dairy products eg full cream Use reduced or low fat cheese.
milk and cheese, full cream yoghurt.
Protein
Protein is a nutrient essential for the bodys growth and repair, as well as having
other important functions in the body. Foods that are rich in protein include
cheese, eggs, fish / seafood, meat and poultry. These foods do not contain
carbohydrate and do not directly affect blood glucose levels. Milk and yoghurt
are rich in both protein and carbohydrate, and will affect blood glucose levels.
These foods need to be considered in the daily carbohydrate requirements.
Protein foods may be high in fat and saturated fat. Small serves of low fat
protein foods should be included each day, for example skinless chicken, lean
beef or meat trimmed of fat, fish, boiled or poached eggs and low fat dairy
products. Legumes and pulses are also good sources of protein. Refer to
Good Food Choices table on page 3 of this section for serve sizes.
! avoid adding salt to cooking and at the table (create flavour with garlic,
onion, spices and herbs)
! choose No Added Salt, Low Salt or Salt Reduced products (remember
these still contain some sodium)
! limit commercially prepared food, takeaways and avoid salty snack foods
(eg crisps and salted nuts)
! steam or microwave your vegetables without adding salt
! cook pasta, rice and potatoes without salt
! check food labels for lower salt products (less than 120mg sodium per
100g is a low salt product; up to 400mg sodium per 100g is a moderate
salt product).
2. Drinking without eating can increase the risk of `hypo for people on insulin or
sulphonylurea medications. It is recommended to have some carbohydrate food
such as wholegrain bread, crackers or the usual meal when drinking alcohol and
to keep a closer check on blood glucose levels.
Pregnancy
Diabetes in pregnancy can be gestational diabetes or pre-existing type 1 or type 2
diabetes (see Pregnancy Section 13). General healthy eating guidelines apply for
women with diabetes who are pregnant or planning pregnancy. Adequate glycaemic
control and a healthy weight can optimise outcomes for both the mother and baby.
Pre-pregnancy medical counselling and review for women with diabetes should occur.
Women planning to become pregnant should take a folic acid supplement of 500mcg
for at least one month before pregnancy and the for the first three months, to reduce
the risk of neural tube defects in the child. Pregnant women with pre-existing type 1
diabetes or type 2 diabetes have higher folic acid supplement requirements; 5mg
supplementation per day is recommended.
Pregnant women with diabetes mellitus need to pay particular attention to the amount
and type of carbohydrate that they eat. Usually women are advised to eat several
small meals throughout the day. Every meal and snack should contain carbohydrate
and should be eaten at consistent intervals each day. Low glycaemic index
carbohydrates can help to manage blood glucose levels.
A dietitian can provide specific advice and support for women with diabetes throughout
their pregnancy and beyond.
Children with type 2 diabetes are often overweight or obese. A healthy eating plan that
limits fats (particularly saturated fats) and limits foods / drinks high in added sugars is
recommended. Regular physical activity is also important. Support and advice that
encourages healthy lifestyle changes should involve the whole family.
Similarly, although children with type 1 diabetes do not have to follow a special
diabetes diet, they may need to pay more attention to when they eat and how much.
Insulin needs to be balanced with carbohydrate intake and activity levels to help
manage blood glucose levels.
Referral to a dietitian is essential for children with diabetes and their families.
Summary
1. General healthy eating guidelines apply for people with and without diabetes.
3. For people using rapid acting insulin their insulin doses should be matched to
carbohydrate intake.
2. The Queen Elizabeth Hospital Diabetes Centre (2007) Healthy eating and
diabetes kit, The Queen Elizabeth Hospital Diabetes Centre, Woodville, South
Australia.
6. Brand-Miller J and Foster-Powell K (2008) The new glucose revolution: The low
GI shoppers guide to GI values, 2008. Hachette Australia, Sydney.
8. Government of South Australia and SA Health (2009) Healthy food and drink
choices for staff and visitors in SA health facilities, SA Health, Adelaide.
People need encouragement and support to accept responsibility and recognise the
importance and consequences of their own lifestyle behaviour. It is extremely difficult
for an individual if they do not have adequate support from health care professionals,
family and friends. Healthy lifestyle changes need to be maintained over a long period
of time and therefore people will need continual support.
Stress
Stress is made up of many things and is caused by a range of different events or
circumstances. Different people experience different aspects and identify with different
definitions. The current consensus on accepted definition of stress is a condition or
feeling experienced when a person perceives that demands exceed the personal and
social resources the individual is able to mobilize. If a person feels that at this point in
time there is simply too much to handle, they will experience stress. How much an
individual can manage will vary at different times.
Stress occurs when the body automatically reacts to a difficult situation which may be
physical (eg illness or injury), or psychological (eg financial or relationship problems).
Underpinning this reaction is fight or flight and the release of a range of hormones,
such as adrenalin. The autonomic nervous system is activated and it is important that
the person is able to counteract the potential damage caused by too much stress,
through regular activity, rest and relaxation to achieve balance.
Health care professionals should ensure that assessment of stress is an integral part of
the assessment process and that stress management strategies are part of the
education plan. The reaction to stress can be very individual and what affects one
person may not affect another. Similarly what one individual can handle will vary from
time to time.
! health problems
! personal trauma
! financial problems
! marital problems
! family problems
! pressure from study / work
! life crises, eg death, accident.
Some people experience stress in relation to things that have not and may never,
happen. We call this worrying. Worry can lead to high levels of stress and in such
cases, assessment of these issues and appropriate referral for counselling is
important.
The person with any lifelong condition such as diabetes has additional stressors
to deal with.
For example:
! simply coping with diagnosis: the person may feel anger, denial or grief following
the diagnosis of diabetes this can come and go over time and is not necessarily
a linear process
! coping with the difficulty of changing lifestyle
! coping with new information and learning new skills
! the need, in many cases, to decrease weight, especially when some find eating a
way of coping with stress
! the need for lifelong daily care
! pain inflicted by prescribed treatments (eg blood glucose monitoring)
! the expense of equipment
! the impact on relationships
! diabetes specific stress, such as hypoglycaemia and needle phobia
! managing social situations
! worry about complications
! coping with understanding the health system.
While most peoples glucose levels go up with emotional / psychological stress, others
may notice their glucose levels can go down. For some people with diabetes,
managing stress with relaxation therapy seems to help. It can be helpful for the person
to become aware of what happens to their diabetes when under stress and how to
manage the stress in order to have less impact. Physical stress, such as illness or
injury, can cause blood glucose levels to go up and down in people with either type of
diabetes.
Stress is usually caused by the reaction people have to what happens to them. Often
the reactions are out of proportion to the event, such as in road rage for example. If
they are able to change their thinking and how they react to certain situations, then
these problems may become less stressful.
Some people however may react with damaging behaviour to cope with stress. For
example they may:
! eat more
! turn to taking drugs, alcohol and / or cigarettes
! stop taking responsibility for their own care
! cause added stress for their loved ones.
Healthy eating is a part of managing stress. A healthy diet can assist the body to
function at an optimum level and better handle stress. Refer to Section 8 for
information on healthy eating for people with diabetes. Exercise is also critical in stress
management.
! encourage regular exercise this is the bodys natural way of reducing stress as
it uses up excess adrenalin and other stress hormones and encourages rest and
relaxation response in the body
! encourage the use of relaxation techniques guided CDs can be very helpful,
particularly if the person has not practised relaxation before and finds it hard to
relax
! encourage the person to find something that assists them in relaxation it might
be walking, singing, swimming, talking to a friend, listening to music
! encourage the use of community resources, eg to stop smoking and / or reduce
alcohol intake
! encourage the person to make connections with other people with diabetes and
someone in their personal network, a family member or friend
! if necessary, consult with the health service social worker/counsellor, clinical
psychologist or general practitioner
! discuss with the medical officer a referral for professional counselling / treatment
cognitive behavioural therapy (CBT) techniques such as thought stopping and
positive visualisation can be helpful
! if a person shows signs of depression, discuss the option of referral for follow-up
with GP and referral for counselling.
WHO (Five) score of below 50 indicates low mood but not necessarily depression. A
score of 28 or below indicates likely depression and warrants further assessment eg a
diagnostic interview with appropriate health professional.
To calculate a score you need to add them up and then multiply by 1.25 (score range is
from 0 100). People scoring 40 or more on the PAID scale may be experiencing
emotional burn out and warrant further individual assessment and possible
intervention. An extremely low score (0 10) combined with poor glycaemic control
may indicate denial. Denial is a normal part of life for many people with diabetes at
times, but persistent denial can be detrimental and needs addressing.
The DDS and the PAID scale are not substitutes for depression screening.
These are just suggestions. Simply asking a person how they are feeling and what is
on their mind can unearth a lot of useful information you just need to listen and allow
them the space to be heard. Questionnaires from the book Diabetes Burnout by
William Polonsky contain a number of exercises around identifying stress and the
impact on diabetes; looking at areas of diabetes that are causing stress; and assessing
diabetes burnout.
Helpful websites
Australian Psychological Society www.psychology.org.au
Australian Association of Social Workers www.aasw.asn.au
Diabetes Counselling Online www.diabetescounselling.com.au
Beyond Blue www.beyondblue.org.au
Black Dog Institute www.blackdoginstitute.org.au
Benefits
! assisting in the utilisation of glucose, thereby enhancing glycaemic control
! regulating appetite and aiding in weight control
! improving cardiovascular fitness
! increasing feel good chemicals in the brain
! helping to reduce stress.
Risks
Overall the benefits of exercise outweigh the risks.7 There is a low prevalence of
musculoskeletal injuries in people who are walking, gardening or cycling. The risk of a
major cardiovascular event has been cited as 1 for every 117,000 hours of activity for
people with cardiovascular disease.7
Hypoglycaemia in people with diabetes who are on some oral hypoglycaemic agents
and / or insulin can occur during and post exercise. It is important for people to be
aware of what precautions they need to take to avoid hypoglycaemia when exercising.
They also need a hypoglycaemia action plan which details strategies for treating
hypoglycaemia when exercising.
Assessment
Before increasing usual activity or exercise levels it is recommended that the person
undergoes a medical assessment.8 The medical history and physical examination
should include signs and symptoms of:
! cardiovascular disease
! eye disease
! kidney disease
! foot problems
! nervous system.
Those most at risk include:8
Moderate intensity physical activity elicits a moderate noticeable increase in depth and
rate of breathing, while still allowing comfortable talking and is relative for a given
person (eg purposeful walking 3-6km/h on level firm ground, water aerobics, cycling for
pleasure < 16km/h and cleaning the house).
A high percentage of people with type 2 diabetes are overweight and this may often be
due to lack of activity.2 People should be encouraged to undertake regular daily
exercise and to manage weight.
Education should include the risks and benefits of exercising, and some of the
following behaviours can be encouraged.
2. Monitor blood glucose before and after exercise (depending on duration may
need to monitor during)
a. identify when changes in insulin or carbohydrate intake are required
b. learn about the glycaemic responses to different types of exercise
c. monitor BGL after exercise and if necessary check overnight
(hypoglycaemia can occur many hours after the exercise is finished.)
3. Food intake
a. eat extra carbohydrate as required
b. ensure that fast and long acting carbohydrates are easily accessible during
and after exercise.
Managing intense or prolonged exercise in people with type 1 diabetes is complex and
requires specialist advice. For further information refer to the article by Riddell.10
If the person has limited mobility, encourage circulation and breathing exercises. These
should be performed once or twice daily for 5 to 10 minutes (if appropriate).
Shoulder exercises
! Lie flat on back, arm at side, palm facing body.
! Keep elbow straight and lift arm until hand points to the ceiling.
! Continue to move the arm back until it rests n the bed next to the head. The arm
may be bent at the elbow if the headboard or the bed will not permit the arm to be
carried all the way back.
! Return to the starting position, rest, then repeat the exercise.
Knee exercises
! Over the edge slowly straighten the leg at the knee and then slowly return to
original position.
! Sitting upright on a bed with legs straight and back well supported slide foot as
far as possible back toward buttocks, bending at the knee. Then slide foot back
to original position. Repeat with other leg.
Ankle exercises
! Slowly bend foot up and down at the ankle.
! Slowly turn feet inwards and then outwards.
! Sitting on the edge of bed, move ankle or foot through circular motion.
Back exercises
! Lying with knees bent, lift hips up from the bed.
! Roll both knees from side to side, but keep shoulders flat on the bed.
! Sit on a chair, feet on the floor. Turn head and shoulders taking arms first round
to the left and then round to the right.
People are advised to discuss the use of alcohol with their GP or diabetes educator.
Alcohol can react adversely with medication.
Alcohol can cause fluctuations in blood glucose levels. The intake of alcohol may also
affect the behaviour and mental state of the individual. The person may fail to
recognise and treat the early symptoms of hypoglycaemia. There may also be some
confusion as to whether excessive alcohol has been consumed, or whether in fact the
person is hypoglycaemic as the symptoms are often similar.
Alcohol taken without food can induce hypoglycaemia therefore it is recommended that
alcohol always be taken in moderation and with food.
The carbohydrate in sweet wine and beer tends to initially raise blood glucose levels.
Dry wines and spirits, are preferable to liqueurs, port and sweet wines. If a mixer is
consumed with spirits, a low calorie mixer or soda water should be used.
The following advice should be given to people with diabetes regarding the use of
alcohol.
! check with your doctor first (discuss any interaction with medications)
! dont drink on an empty stomach
! avoid drinking in excess (no more than 2 standard serves [20 grams] is recommended
each day)
! choose low alcohol drinks
! choose dry wines and spirits
! choose light beer
! choose sugar-free mixers such as soda or low joule mixers
! avoid or limit all alcohol if you are trying to lose weight
! pregnant women should not drink alcohol because of the risks to the foetus
! it is not advisable to drive after drinking alcohol
! wear diabetes identification.
The resulting vascular disease, particularly in the legs, kidneys and eyes and cardiac
disease, reduce the quality of life for the individual and may even be fatal. Cigarette
smoking is the most important modifiable cause of premature death.11
! Ask ensure that every person is asked if they smoke. Those who do smoke
can be asked at each visit.
! Assess for current smokers assess their interest in quitting.
! Advise provide information about how important it is for them to quit.
! Assist help people set a quit date and provide information and resources
about how to prepare. Some people may like to seek specific counselling, others
may want medication to assist them.
! Arrange ensure adequate follow up is arranged eg phone call or appointment
If a person with diabetes is planning to travel overseas it will be important for them to
seek advice about insurance before purchasing their tickets. It may be helpful to
discuss the best options for travel insurance with Diabetes Australia or their travel
agent.
Example: If you have felt cheerful and in good spirits more than half of the time during
the last two weeks, put a tick in the box with the number 3 in the upper right corner.
Over the last two All of the Most of More than Less than Some of At no time
weeks time the time half of the half of the the time
time time
1 I have felt
cheerful and in
5 4 3 2 1 0
good spirits
4 I woke up feeling
fresh and rested 5 4 3 2 1 0
Scoring:
The raw score is calculated by totalling the figures of the five answers. The raw score
ranges from 0 to 25, 0 representing worst possible and 25 representing best possible
quality of life.
To obtain a percentage score ranging from 0 to 100, the raw score is multiplied by 4. A
percentage score of 0 represents worst possible, whereas a score of 100 represents
best possible quality of life.
Interpretation:
It is recommended to administer the Major Depression (ICD-10) Inventory if the raw
score is below 13 or if the patient has answered 0 to 1 to any of the five items. A score
below 13 indicates poor wellbeing and is an indication for testing for depression under
ICD-10.
Monitoring change:
In order to monitor possible changes in wellbeing, the percentage score is used. A 10%
difference indicates a significant change.
INSTRUCTIONS: Which of the following diabetes issues are currently a problem for you?
Circle the number that gives the best answer for you. Please provide an answer for each question.
Somewha
Not a Minor Moderate Serious
t serious
problem problem problem problem
problem
0 1 2 3 4
10. Feeling angry when you think about living with diabetes? 0 1 2 3 4
13. Feelings of guilt or anxiety when you get off track with
0 1 2 3 4
your diabetes management?
18. Feeling that your friends and family are not supportive of
0 1 2 3 4
your diabetes management efforts?
Directions. Living with diabetes can sometimes be tough. There may be many
problems and hassles concerning diabetes and they can vary greatly in severity.
Problems may range from minor hassles to major life difficulties. Listed below are 17
potential problems that people with diabetes may experience. Consider the degree to
which each of the items may have distressed or bothered you DURING THE PAST
MONTH and circle the appropriate number.
Please note that we are asking you to indicate the degree to which each item may be
bothering you in your life, NOT whether the item is merely true for you. If you feel that
a particular item is not a bother or a problem for you, you would circle 1. If it is very
bothersome to you, you might circle 6.
Directions. Living with diabetes can sometimes be tough. There may be many
problems and hassles concerning diabetes and they can vary greatly in severity.
Problems may range from minor hassles to major life difficulties. Listed below are 17
potential problems that people with diabetes may experience. Consider the degree to
which each of the items may have distressed or bothered you DURING THE PAST
MONTH and circle the appropriate number.
Please note that we are asking you to indicate the degree to which each item may be
bothering you in your life, NOT whether the item is merely true for you. If you feel that
a particular item is not a bother or a problem for you, you would circle 1. If it is very
bothersome to you, you might circle 6.
3. Psychiatric Research Unit WHO Collaborating Centre for Mental Health (1998)
WHO-Five Well-being Index (WHO-5). [Cited 2 September 2009]; Available
from: http://www.who-5.org/
10. Riddell M C and Perkins B A (2006) Type 1 diabetes and vigorous exercise:
Applications of exercise physiology to patient management. Canadian Journal
of Diabetes, 30(1): p63-71.
The aim of this section is to provide basic information about each of the diabetes
medications. We recommend you refer to the MIMS Annual for specific details
including interactions between various medications.1
! biguanides (metformin)
! sulphonylureas
! meglitinides (glitinides)
! glitazones
! alpha-glucosidase inhibitors
! incretin enhancers and mimetics.
Note: medication will not substitute for healthy eating, weight reduction and / or
exercise and the benefits of these need to be reinforced.
There are various treatment algorithms that are being used nationally and
internationally. The recently released algorithm from the NHMRC states that 4;
! interventions to achieve target HbA1c should begin with lifestyle modification
followed by therapeutic options which are selected on the basis of the individual
circumstances, side effects and contraindications
! for people with significant hyperglycaemia pharmacotherapy should be
commenced in addition to lifestyle modification.
The Australian algorithm is consistent with the UK NICE (2008)5 guideline for type 2
diabetes and the IDF guideline (2005)6 both of which recommends a trial of lifestyle
modification and increased physical activity before considering metformin therapy.
While, the recently published consensus statement from America and Europe
recognises that supporting the person to make lifestyle improvements is integral they
suggest that for most individuals, lifestyle interventions alone fail to achieve or maintain
metabolic goals. Their consensus was that metformin should be started at diagnosis
alongside lifestyle interventions (unless metformin is contraindicated)2
The NHMRC management algorithm can be seen on page 3 (Figure 1)4. The algorithm
for commencing and titrating insulin in type 2 diabetes can be found on page 22 of this
section. Alternatively the RACGP guidelines have a management algorithm on page
39 7. These can be accessed at www.racgp.org.au/guidelines/diabetes.
Lifestyle modification
! diet modification
! weight control
! physical activity
Metformin
Sulphonylurea
! The algorithm includes only therapeutic agents available through the PBS.
! If HbA1c >7 consider intensifying treatment provided hypoglycaemia is not a
problem.
# Authorised only as dual therapy with metformin or sulphonylurea where
combination metformin and sulphonylurea is contraindicated or not tolerated.
* Rosiglitazone is not authorised for triple therapy or for use with insulin (from
February 1 2009) but is approved only as dual therapy with metformin or
sulphonylurea where combination metformin and sulphonylurea is
contraindicated or not tolerated.
This algorithm has been adapted from The NHMRC Blood Glucose Control
guidelines 4
(a) Care renal, gastrointestinal disease. (e) Care renal, liver and cardiovascular
(b) Sulphonylurea disease.
(c) Metformin (f) Authority required
(d) Glitazone (g) Private script
(h) Care, renal insufficiency
Note: oral agents need to be used with special care in the elderly.
Ensure that patient is aware of the name, dose, dosing time, action and side effects of
their medication.
Action
! Reduces hepatic glucose production.
! Increases peripheral utilisation of glucose in muscle and fat tissues.
! Decreases intestinal absorption of glucose.
! Decreases insulin requirements for glucose disposal.
Contraindications
! Hypersensitivity to metformin.
! Severe renal impairment (creatinine clearance <30ml/min).
! Ketoacidosis.
! Respiratory failure.
! Severe infection or trauma; substitute with insulin treatment.
! Severe dehydration.
! Alcohol abuse.
Precautions
! Mild to moderate renal impairment reduce dose.
Consider the following dosages based on creatinine clearance:
! 6090mL/minute, 2g/day in divided doses
! 3060mL/minute, 1g/day once daily or in divided doses.
! Severe hepatic disease.
! Acute congestive heart failure, recent MI, moderate to severe heart failure.
! Conditions which may be associated with tissue hypoxia eg Gangrene.
! Conditions predisposing to lactic acidosis eg metabolic acidosis.
! The very old (eg >85 years).
! Surgery or patients receiving parenteral iodinated radiograph contrast media (see
Important Considerations below).
! Pregnancy.
Side effects
Gastrointestinal side effects are common with metformin and transient. In most patients
they are dose related and can be minimised by dose reduction or gradual dose
escalation. Metformin should be taken with or after meals to minimise gastrointestinal
side effects.
Common
! Gastrointestinal disturbances eg nausea, vomiting, anorexia, abdominal pain,
diarrhoea.
! Metallic taste.
! Low vitamin B12 levels.
Important considerations
! Metformin may need to be stopped prior to (48 hours) and after surgery or
contrast media (iodinated) depending on renal function and volume of contrast.
Always confirm with medical staff or local hospital protocols.9
! Metformin should also be used with caution in any severe illness in which tissue
oxygenation is potentially reduced (acute respiratory failure, MI, cardiac failure
etc).
! Hypoglycaemia is uncommon in patients taking metformin alone, but may occur
when it is used in combination with other hypoglycaemic agents or insulin.
Action
! Increase pancreatic insulin secretion.
! May improve insulin sensitivity in peripheral tissue and decrease hepatic glucose
output.
Contraindications
! In pregnancy, due to possible teratogenic effects.
! In major surgery, due to possible hypoglycaemic effects.
! Hypersensitivity to sulphonylureas.
! Type 1 diabetes.
! Ketoacidosis.
! Severe renal impairment. (Please consult with GP/MO if concerned).
! Severe hepatic impairment.10
Precautions
! Mild to moderate renal impairment.
! Elderly people (use agent with lowest risk of hypoglycaemia see Important
Considerations below).
! Severe infection, trauma or other conditions where sulphonylureas are unlikely to
control blood glucose; substitute with insulin treatment.
Side effects
Common
! Hypoglycaemia.
! Weight gain.
! Transient visual disturbances eg. Blurred or double vision.
Action
! Transiently increases pancreatic insulin secretion (similar to sulphonylureas but
acts at a different binding site).
Contraindications
! Hypersensitivity to repaglinide.
! Type 1 diabetes.
! Ketoacidosis.
! Children under 12 years.
! Pregnancy and lactation.
! In major surgery, due to possible hypoglycaemic effects.
Precautions
! Impaired renal function.
! Impaired hepatic function.
! Hypoglycaemia.
! Severe infection, trauma or other conditions where meglitinides are unlikely to
control blood glucose; substitute with insulin treatment.
Side effects
Common
! Hypoglycaemia.
! Gastrointestinal disturbances eg nausea, abdominal pain, dyspepsia,
constipation and diarrhoea.
Important considerations
! Repaglinide has a short duration of action and rapid onset of action. It should
therefore be taken immediately before meals.
! The dose of repaglinide should be missed if a meal is skipped. If a meal is added
then a dose should be added. It has the principle of One meal one dose, no
meal no dose.
! Ensure that patient is aware of the symptoms of hypoglycaemia so that they can
recognise, treat and take measures to prevent it.
Action
! Increase the sensitivity of peripheral tissues to insulin.
! Decrease hepatic glucose output.
Contraindications
! Hypersensitivity to the drug.
! Ketoacidosis.
! Heart failure NYHA Class III and IV.
! Moderate to severe hepatic impairment and where ALT >2.5 times the upper limit
of normal.
! Type 1 diabetes.
! Known ischaemic heart disease (IHD)
! Rosiglitazone is contraindicated in patients IHD, particularly those taking
nitrates as it has been shown to increase the risk of myocardial
ischaemia.13 Pioglitazone does not appear to carry the same risk.
Precautions
! Patients with oedema or mild heart failure, due to risk of fluid retention.
! Anovulatory premenopausal women with insulin resistance as ovulation may
resume, therefore consider contraception.
Side effects
Common
! Oedema.
! Weight gain.
! Headache.
! Arthralgia.
! Dizziness.
! Decrease in haemoglobin and haematocrit.
! Increase in total and HDL cholesterol (rosiglitazione).
Action
! Inhibits the alpha-glucosidase enzymes in the small intestine, which break down
carbohydrates such as starch and sucrose. This action delays the absorption of
carbohydrates and thus decreases the sharp, post-prandial rise in blood glucose
that occurs after meals.
! Acarbose does not affect the absorption of simple sugars eg glucose and
fructose.
Contraindications
! Inflammatory bowel disease.
! Partial intestinal obstruction (or predisposition).
! Gastrointestinal disorders associated with malabsorption.
! Conditions aggravated by formation of intestinal gas eg hernias.
! Severe renal impairment.
! Hypersensitivity to acarbose.
! Pregnancy.
! Patients <18 years.
Precautions
! Ingestion of large amounts of food containing carbohydrate (including sucrose)
can lead to gastrointestinal symptoms (flatulence, large amounts of bloating or
diarrhoea) during treatment, due to carbohydrate fermentation in the colon. The
symptoms are dose dependent and unlikely to be alleviated by taking an
antacid.10 However, they can be reduced by starting patients on low dose and
increasing gradually.
! May elevate serum transaminase levels. Decrease dosage if transaminases are
elevated and stop treatment if elevations persist.
Side effects
Common
! Gastrointestinal disturbances eg flatulence, abdominal pain and distension,
diarrhoea, dyspepsia, nausea.
Enhancers (sitagliptin)
Action
Sitagliptan is currently the only agent available in this group. The incretin enhancers
are oral medications and slow the breakdown of endogenous GLP-1 They increase
glucose-dependent insulin secretion and reduce glucagon production. 10
Contraindications
! Hypersensitivity to sitagliptin.
! Breastfeeding.
! Type 1 diabetes.
! Diabetic ketoacidosis.14
Precautions
! Renal impairment consider dosage reduction for creatinine clearance <50
ml/min.10
! Age <18 safety and efficacy have not be proven in this group.14
! Pregnancy.
Side effects
Common
! Upper respiratory tract symptoms.
! Headache.
! Nausea.
Important considerations
! Not associated with weight gain.
! Do not cause hypoglycaemia unless used with a sulphonylurea or meglitinide.
Action
Exenatide is currently the only agent available in this group. It is an injected medication
(given subcutaneously) which binds to the GLP-1 receptor to enhance insulin secretion
and suppress inappropriate glucagon secretion. It also delays gastric emptying, which
reduces the rate of glucose absorption, and decreases appetite.
Contraindications
! Hypersensitivity to exenatide.
! Type 1 diabetes.
! Diabetic ketoacidosis.
! Severe gastrointestinal disease eg gastroparesis, dumping syndrome.
! History of pancreatitis with exenatide.
! Severe renal impairment.
! Pregnancy.
! Breastfeeding.
Precautions
! Renal impairment consider dosage reduction for creatinine clearance
<30ml/min.14
! Age <18 safety and efficacy have not be proven in this group.
Side effects
Common
! Gastrointestinal disturbances eg nausea and vomiting (occurs in up to 50% of
patients but usually improves with continued treatment), diarrhoea, dyspepsia,
GORD, abdominal pain.
! Headache, dizziness, feeling jittery.
! Injection site reactions.
Important considerations
! Used as an adjunct to metformin and / or a sulphonylurea.
! May aid weight loss in patients with BMI >25.
! Hypoglycaemia is unlikely unless used with a sulphonylurea or meglitinide.
! Less frequent blood glucose monitoring is required with exenatide than with
insulin.
Insulin levels increase after a meal and fall as the glucose levels fall to maintain blood
glucose levels within a normal range.
Action
! Enhances cellular uptake of glucose.
! Inhibits hepatic glucose production.
! Stimulates glycogen formation and storage in the liver.
! Promotes protein synthesis and storage of fat.
Insulin therapy should therefore aim to mimic these actions and maintain blood glucose
levels to as near normal as possible.
Indications
! Type 1 diabetes.
! Type 2 diabetes inadequately controlled with diet, exercise and oral
hypoglycaemic agents and in conditions where oral hypoglycaemic agents
cannot be used eg pregnancy, surgery, trauma.
Types of insulin
Insulin is derived from:
Human insulin is usually absorbed faster than bovine insulin, however it often has a
shorter duration.
There are numerous insulin preparations in Australia. The insulins are manufactured by
a number of companies, who produce brands that are of similar insulin type and
duration of action. For example Actrapid and Humulin R are both short acting or
soluble insulins (refer to table on comparative information for insulins).
The type of insulin chosen and the insulin schedule should be based on the individuals
needs and lifestyle. The medical officer will discuss the appropriate schedule with the
person.
! Ultra short acting insulin lispro, insulin aspart, and insulin glulisine are soluble,
ultra-short acting insulins. They are identical to human insulins except for some
molecular structural changes in the insulin chain. As a result, they have more
rapid onset of action, which allows them to be given immediately before meals.
! Short acting also called regular, neutral and soluble insulin. This insulin is
clear and short acting.
Intermediate acting
(12-24hrs) Humulin NPH Lilly Human
Isophane Protaphane Novo Nordisk Human
Hypurin Isophane Aspen Bovine
Pre-mixed insulins
Lilly Analogue
Lispro 25% Humalog Mix 25 +
Lispro protamine 75%
Lilly Analogue
Lispro 50% Humalog Mix 50 +
Lispro protamine 50%
Novo Nordisk Analogue
Insulin aspart 30% NovoMix 30 +
Insulin aspart protamine 70%
Lilly Human
Neutral 30% Humulin 30/70 Novo Nordisk Human
Isophane 70% Mixtard 30/70
Type 2 diabetes
A simple and safe way to initiate insulin is to add bed-time basal (isophane or
analogue) insulin to oral antidiabetic agents.
Step 2 ADJUST Insulin therapy gradually every 3-4 days according to fasting blood
glucose (FBG) level until target FBG is reached (usually 4.0-6.0 mmol/L)
Step 3 CHECK overall blood glucose control by measuring HbA1c 3-6 monthly.
Step 4 If FBG and evening blood glucose are on target but HbA1c is not, look for
hidden hypers blood glucose peaks that occur during the day, often before
lunch or after dinner.
Options to correct hidden hypers include:
! changing preceding meal size or composition
! increasing activity after meals
! adding acarbose
! adding a meal-time rapid acting insulin.
Continuing oral antidiabetic agents minimises the risk of weight gain and
hypoglycaemia.
The choice of insulin types and regimen has to be guided by a variety of factors,
including:17
Most adolescents and adults with type 1 diabetes will be on a four injections per
day (basal-bolus) regimen.
With main meals, with intermediate-acting insulin given in the evening or in the morning
and evening, or with glargine given once daily (morning or evening).
As an inpatient, the registered nurse assigned to care for the person is responsible for:
! checking the medication sheet order (question any discrepancy with the medical
officer)
! checking the correct insulin type, dose and time of administration has been
documented
! checking blood glucose level prior to administering the insulin
! checking that the injection is given and supervising persons self-administration (if
able), people are encouraged to continue to maintain their self-care while in
hospital
! supervising and assessing injection technique and site
! use a new needle each time
! prime the needle
! insulin currently in use must not be refrigerated
! mix insulin gently (rock and roll)
! count to ten after injection before removing the needle
! rotate injection sites on the abdomen keep the needle steady
! consulting the diabetes educator if necessary
! people commencing insulin need to be educated about identification, treatment
and prevention of hypoglycaemic episodes
! documenting action taken and subsequent progress.
! Insulin type and dosages will vary from person to person. People with type 1
diabetes will have different insulin requirements than those with type 2 diabetes
or gestational diabetes. Dosage and effect will vary from time to time for the
same person.
! When the person with type 1 diabetes is nauseated or unwell and not eating, as
close to usual dose of insulin should be maintained. Food intake needs to be
substituted with liquid carbohydrates such as soups, fruit juice or lemonade.
! Some people with type 1 diabetes receiving short acting insulin (eg Actrapid or
Humulin R) require mid-meal snacks and supper.
! People who receive intermediate / long acting insulin without other insulins, do
not generally need snacks unless otherwise indicated.
! If on a twice daily intermediate acting insulin, 2/3 of the dose is usually given in
the morning, with 1/3 of the dose before the evening meal.
! If person has P.E.G. feed, please check that the time / action profile of the
prescribed insulin coincides with the time-action profile of the feed.
! People who are receiving insulin therapy and are unable to eat, may be able to
tolerate oral carbohydrate drinks. If not, please contact the medical officer for
review of insulin therapy / IVT.
! Ultra short and short acting insulins are soluble insulins and are the only type that
can be given intravenously.
! Long acting insulin analogues cannot be mixed with any other insulin and must
be injected separately.
Side effects
! Hypoglycaemia.
! Weight gain.
! Local reactions lipodystrophy, lipoatrophy, erythema, pruritis, allergic reactions.
Storage of insulins
! Unopened insulin should be stored in the refrigerator.
! Do not freeze insulin.
! Once opened insulin can be stored at room temperature (not exceeding 30oC) for
28 to 30 days (depending on the product) as indicated on the label. Please
check product information enclosed with the insulin.
! In hospital, use a one vial or cartridge / one patient policy. Label and date the
vial / cartridge when opening them.18
! Store the insulin you are using out of the fridge and away from direct sunlight.
! Ideally, while in hospital, the person should be encouraged to continue self-care
insulin administration. In this case, identify a suitable storage place and store it
at room temperature.
! Discard insulin if it is discoloured, has changed in appearance in any way or the
expiry date has been reached.
! Insulin is damaged by heat and must not be kept in the car or where the
temperature exceeds 30oC.
! If travelling, spare insulin can be kept in a cool bag or vacuum flask.
! If the abdomen is unsuitable, for example, in a person who has had abdominal
surgery, then the buttocks or thigh can be used.
! Do not use the same spot in the chosen site every time. Move the site around to
avoid discomfort and to make sure that the insulin is absorbed evenly. This will
also decrease the risk of lipohypertrophy and / or lipoatrophy.
! Assess injection sites and condition of skin. Check for any swelling, hard
nodules, indentations, inflammation or pain.
! There is no need to swab the skin with alcohol before injection of insulin.
Insulin variability
The rate of onset, maximum effect and duration of effect will vary between patients.
Variables that may influence the actions of insulin include:
! injection site
! local injection site reactions (eg. scars)
! depth of injection
! local massage
! temperature
! exercise
! insulin mixing.
5. With the vial upright inject the air into the insulin vial.
5. Dispose of the syringe safely as per hospital policy for `sharps disposal.
dial rotated to
replaceable needle deliver dose
to deliver the dose
Figure 4
Nursing staff are not to administer insulin using an insulin delivery device (eg Innolet or
pen) with removable pen needles unless the patient is able to self administer
independently (ie self inject and then safely dispose of the needle).
If the patient is self administering then it is appropriate for the nurse and patient to
check that the dose and time is correct. The nurse then has a supervisory role to
ensure correct injection technique and appropriate disposal of sharps.
Note: The Department of Health and Ageing Infection Control guidelines state to
prevent injury, needles should not be re-sheathed unless an approved recapping
device is used.19
There is no approved re capping device for pen needles (the devices supplied by the
pharmaceutical company have not been approved for recapping).
Background20
Safe disposal of needles, syringes and lancets is becoming more important with the
increased fear of transmission of infectious diseases, and a growing awareness of
environmental issues.
Many hospitals and health institutions have formulated their own policies for handling
and disposing of sharps. However, no national policies or guidelines exist for
community situations.
In reaching its policy statement, Diabetes Australia recognises that there is only one
means of safe disposal of needles, syringes and lancets within the community and that
is to use an approved, puncture-resistant container. Anything less than this (eg
recapping, clipping or using other sub-standard containers) has the potential to cause
wounds and infections.
Health professionals involved in diabetes education should act as advocates and
promote the necessary skills and education for people with diabetes about the safe
disposal of needles, syringes and lancets.
Supply of syringes
Register with the National Diabetes Services Scheme through Diabetes Australia for
syringe supply.
Inform person about the availability of syringes / needles without cost and the fact that
they can be mailed out.
Check your exercise - if strenuous you will need to adjust insulin / food
Normally a pancreas secretes a basal amount of insulin over the entire 24 hour period.
Although this basal rate varies, there is always insulin present. In addition there is an
increase (bolus) in insulin that is secreted automatically in response to food
(carbohydrate) intake. Insulin pump therapy aims to mimic the normal physiologic
response by providing continuous basal insulin as well as the ability to provide bolus
doses whenever there is intake of carbohydrate containing food.
Insulin pump therapy is becoming more widely used both in metropolitan and rural
Australia. It is anticipated that this increased utilisation of pump technology will result
in more and more patients being admitted to hospital on insulin pump therapy.
When a person is started on an insulin pump they require intensive education and
support by a multidisciplinary team including endocrinologist, diabetes educator,
dietitian and in some cases a social worker. This team has been trained and is
experienced at managing insulin pump therapy. A list of Insulin Pump Centres is
available on the Australian Diabetes Educators Association website
(www.adea.com.au). If the person lives in a rural or remote area arrangements will
need to be made for a shared care arrangement with an Insulin Pump Centre. The
diabetes team from the Insulin Pump Centre will ensure appropriate resources and
support are available prior to and after commencing the patient on pump therapy. A
shared care arrangement helps country diabetes educators to develop and maintain
skills in pump education (eg carbohydrate counting, using the pump and managing
hypo and hyperglycaemia).
For information about pump therapy whilst a person is in hospital, please refer to
Hospitalisation Section 4.
Insulin name and dose (please circle) - (as cited letter / phone / GP form / casenotes): Given Names: ________________________________________
LEGEND FOR THE FOLLOWING TABLES (If the section is not applicable then write NOT APPLICABLE next to the DATE)
L Low knowledge/skills, unsafe, new diagnosis or has no information. Does not understand basic information and needs reinstruction.
M Medium knowledge skills or states demonstrate they may require reinforcements, supervision and explanation. Understands basic information and
demonstrates necessary skills for safe self management.
H High knowledge/skills safe, able and aware. Assumes responsibility for care and applies knowledge for safe self management.
SIGNATURE:
BLOOD GLUCOSE MONITORING QA test date: Competent technique:
Yes % No %
11. Novo Nordisk Pharmaceuticals Pty Ltd. (2009) NovoNorm Product Information
[Cited 3 April 2009 (subscription required)]; Available from:
www.mimsonline.com.au
12. National Prescribing Service (2008) Early use of insulin and oral antidiabetic
drugs. National Prescribing Service Newsletter PPS. [Cited December 2008];
Available from:
http://www.nps.org.au/health_professionals/publications/prescribing_practice_re
view/current/early_use_of_insulin_and_oral_antidiabetic_drugs
16. Australian Diabetes Educators Association (2004) National standards for the
development and quality assessment of services initiating insulin therapy in the
ambulatory setting. Australian Diabetes Educators Association, Canberra.
18. The Queen Elizabeth Hospital (2002) Medication management. The Queen
Elizabeth Hospital, Adelaide.
19. Department of Health and Ageing (2004) Infection control guidelines for the
prevention of transmission of infectious diseases in the health care setting.
Department of Health and Ageing, Canberra.
20. Diabetes Australia (1992) National policy statement for safe disposal of
needles, syringes and lancets. Diabetes Australia, Canberra.
22. New South Wales Insulin Pump Interest Group (2006) Insulin pump therapy: An
information booklet for diabetes health professionals interested in establishing
an insulin pump therapy service. Diabetes Australia & ADEA, Canberra.
Hypoglycaemia
Hypoglycaemia occurs when the blood glucose level falls to values low enough to
cause symptoms and signs. When the level of glucose falls in the blood the cells in the
periphery, and eventually the brain cells do not get adequate glucose to function. The
value at which this occurs is defined at below 4mmol/L but probably differs according to
the age and sex of the person, whether there are any associated medical conditions
such as liver disease or cerebrovascular disease present and the rate at which blood
glucose level has fallen. Significant hypoglycaemic symptoms tend not to occur until
blood glucose levels fall below 4mmol/L.1
Type 1 diabetes
Hypoglycaemia is very common for people with type 1 diabetes. For those who are
wanting to improve or maintain target glycaemic control symptomatic hypoglycaemic
episodes may occur on average 2 times a week. Severe hypoglycaemia may occur
approximately 1 time per year.1 It has been estimated that 2-4% of deaths of people
with type 1 diabetes have been attributed to hypoglycaemia.
Type 2 diabetes
The frequency of hypoglycaemia is substantially lower in type 2 diabetes as compared
with type 1 diabetes. The rate of severe hypoglycaemia in type 2 diabetes are less
than 10% of those in type 1 diabetes at the same level of A1c.1 Hypoglycaemia
becomes more problematic for people with type 2 diabetes as their diabetes
progresses and they become more and more insulin deficient. Deaths have been
documented in people with type 2 diabetes who are on sulphonylurea medications.
At about 3.7mmol/L the secretion of glucagon is increased and this results in the
release of stored glucose. Other hormones such as epinephrine, cortisol and growth
hormone are also released in order to raise the blood glucose.1
Hypoglycaemia can be defined on the basis of physiology using the terminology mild,
moderate or severe (table 1).
Table 1
Mild Moderate Severe
Not capable of self-
Capable of self treating May require prompting
treatment
Hypoglycaemia at night is often slept through and not noticed. Symptoms of unnoticed
nocturnal hypoglycaemia include:
! morning headaches
! hangover type feeling on waking
! nocturnal sweating.
Management
Hypoglycaemia must be treated promptly. People with diabetes should have a
hypoglycaemia action plan which clearly steps out their management.
The following is a suggested protocol for the treatment of people with hypoglycaemia in
the community. This protocol may be adapted for any hypoglycaemic situation. You
should refer to Hospitalisation Section 4 for the hypoglycaemia protocol for health
services and hospitals.
Step 1
! 15gm fast acting carbohydrate (CHO)
eg 150mls soft drink
or 15g Glucose tablets
or 6 jelly beans (glucose)
! Wait 5-10 minutes
! Repeat Step 1 if BGL still <4mmol/L
! If blood glucose level "4mmol/L, move to Step 2.
Step 2
! Slow acting CHO intake
eg 4 water crackers or equivalent or
1 piece of fruit or
1 cup of milk or
meal if only minutes away.
Glucagon (GlucaGen)
Glucagon should be prescribed for all individuals who are at significant risk of severe
hypoglycaemia eg past history of severe hypo or hypo unaware. Caregivers or family
will require instruction.2
Glucagon is a hormone that increases glucose levels in the blood. It does this by
releasing glucose from stored carbohydrate (glycogen) in the liver into the blood. This
means that glucagon will only work to increase blood glucose if there are stores of
glycogen in the liver.
People need to be informed that they will need a script and that they will need to check
expiry dates. Ambulance cover and medic alert are recommended.
It is important to inform the person and their family that if they phone an ambulance
they will be connected to a qualified SAAS call-taker. The call-taker will immediately
assess the situation and can give step-by-step instructions over the phone. This can
provide much needed support during a stressful event. The call taker will assess the
severity and an ambulance will be dispatched if required. Visit the website
www.saambulance.com.au for more information about the ambulance service.
If the person is unconscious, turn on to their side and get help immediately.
Advice for non-medical person: inject the dose of glucagon into the fatty tissue just
below the skin of the thigh or buttocks.
! Adults and children above 25kg: inject full dose (marked on hypokit syringe as
1/1mL)
Children below 25kg: inject half dose (marked on hypokit syringe as 1/2mL)
! The person will normally respond within 10-15 minutes to the injection of glucagon.
! Once conscious, follow usual guide for hypo treatment. Note: It is advisable not to give
food immediately as the person may feel nauseous. Slow sips of a sweet drink is
sufficient.
! People also often have a distressing headache after a severe hypo and they can
be advised to sleep once BGLs are stabilised.
! After a severe hypo the liver stores of glucose may be depleted and so the
person needs to be warned that they are at an increased risk of further hypos.
GlucaGen Hypokit should be stored at room temperature (eg less than 25oC).
The expiry date (Expiry) is printed on the pack. If passed this date, do not use it.
Check the expiry date from time to time to make sure that the glucagon in your
GlucaGen Hypokit has not expired.
The glucagon solution should be injected immediately after it is prepared. It should not be stored for later use.
For further information consult the Product Information leaflet. Information is also
available from Novocare Customer Care Centre on 1800 668 626.
Monitor
Monitor person 15-30 minutes following treatment.
Check blood glucose level after 30 minutes from initial time. If blood glucose level is
<4 repeat Steps 1 and 2 on page 3. It is necessary to ensure that the hypoglycaemia
does not recur and blood glucose level remains within normal range.
Length of observation
The person should be aware that hypoglycaemia might reoccur and that increased
testing for the next 24 hours may be needed. This will depend on the severity and
duration of episode. Some form of fast acting, rapidly absorbed carbohydrate should
be left with the person. After a severe episode of hypoglycaemia the next dose of
medication may need to be modified and the person should discuss their needs with
the appropriate health professional. The person should also be encouraged to
determine the cause of the hypoglycaemia wherever possible to assist in preventing
further episodes.
Hypoglycaemic unawareness
Some people with diabetes may not have any symptoms of hypoglycaemia.
Unawareness of hypoglycaemia symptoms occurs more frequently in people who have
had diabetes for many years or in people who maintain lower blood glucose levels.
Diabetic neuropathy can also lead to hypoglycaemic unawareness.
Education and support for partners / carers and the person themself are also important
issues in managing hypoglycaemic unawareness.
People with diabetes should be instructed to carry some form of quick acting
carbohydrate at all times. Educate people at risk to carry an identification card or wear
a bracelet.
Advise people to check their blood glucose level or institute treatment at the first
indication of possible hypoglycaemia.
If hypoglycaemia occurs frequently they must discuss this with the GP / MO so that
some adjustment is made to their treatment plan. Adults trying to lose weight or
maintain their current weight may need to have their medication dosage decreased.
Educate family members and close friends about hypoglycaemia and teach them when
and how to measure blood glucose levels and the use of glucagon injection.
Educate people with diabetes who are at risk of hypoglycaemia to employ special care
(eg increased monitoring, including 3am glucose checks) when activity and diet
patterns are altered, when planning to drive or while driving.
My hypo plan
or ____________________________
Step 4 monitor BG 1-2 hour increasing gap time until happy no repeat
hypo
or ____repeat BG in 1 hour_________
Primary causes
! insufficient insulin, omitting the insulin injection
! insufficient oral hypoglycaemic agents or omitting to take medications as prescribed
! excessive carbohydrate intake
! stress physical stress increases the bodys energy demands, which increase the
production of glucose and counter regulating hormones. Insulin or oral
hypoglycaemic agents therefore are less effective
! infection and illnesses - gastroenteritis, myocardial infarction, urinary tract infection
! surgery
! rebound hyperglycaemia Somogyi effect
! other medications, eg steroids such as prednisolone.
Assessment of hyperglycaemia
Assessment is crucial to prevent hyperglycaemia progressing to an advanced
metabolic crisis. This can be prevented by early recognition of signs and symptoms
and prompt treatment. To assess hyperglycaemia:
Ketoacidosis
Diabetic ketoacidosis (DKA) is a medical emergency which has a <5% mortality.4 It is
preventable in people known to have type 1 diabetes and most cases of ketoacidosis
occur in patients with undiagnosed type 1 diabetes.
Ketoacidosis results from the absence of insulin. Although small amounts of circulating
insulin may be present, the presence of large amounts of the counter regulatory
hormones such as glucagon, adrenaline and noradrenaline and cortisol, result in the
insulin being less effective.
Insulin
Glucagon and
deficiency
counter-regulatory
hormone excess
Reduced glucose
Lipolysis Glycogenolysis
uptake
Ketogenesis Gluconeogenesis
into tissues
Ketosis Hyperglycaemia
Severe Dehydration
! Illness / infection.
! Inadequate insulin administration either by the MO or the person with diabetes.
People with gastrointestinal infections often decrease or omit insulin when food
intake is decreased. (The person must be educated regarding appropriate
management during sick days and advised that adjustment of insulin dosages
based on blood glucose levels may be required).
! First presentation of type 1 diabetes.
Features of ketoacidosis
Glycosuria: occurs as the concentration of glucose in the blood exceeds the renal
threshold (ie capacity to reabsorb).
Polyuria: glucose in the urine acts as an osmotic diuretic, which can lead to
dehydration if left untreated.
Polydipsia: thirst will occur as the body attempts to replace the lost fluid.
Ketones: as fats are broken down to supply energy, ketoacids accumulate in the
blood stream causing ketosis and acidosis. Ketosis is also recognised by an acetone
breath. The accumulation of ketones in the blood and excretion of ketones in the urine
(ketonuria) leads to more electrolyte imbalance and dehydration.
Polyuria, ketonuria and acidosis cause loss of body potassium. However, acidosis
causes potassium to move from the cells to the plasma. Hence, the circulating
potassium may be low, normal or high.
If acidosis and hyperglycaemia continue, they may lead to coma and death.
Prevention
! Awareness of the early signs and symptoms of uncontrolled diabetes must be
increased. People with diabetes and their family need education.
! The importance of ketone testing during illness should be stressed for people
with type 1 diabetes.
! Management of sick days in the home situation with increased knowledge and
skills is a major factor in prevention.
! Professional education with regard to proper diagnosis and treatment.
! Psychological intervention will need to be included as part of the treatment for
those who have recurrent episodes requiring admission to hospital.
If the person is unable to replace fluids, dehydration and mental impairment occurs.
This is especially likely in the elderly. Hence this acute complication often occurs in the
elderly on oral hypoglycaemic agents who may be inadequately monitored or not
receiving adequate fluid intake and unable to communicate their need.
Precipitating factors
These include:
! infection
! intercurrent illness such as myocardial infarction, acute airway disease
! medication, eg high dosage corticosteroids, excessive use of diuretics
! pancreatitis
! total parental nutrition
! renal dialysis
! severe burns.
Teach people with diabetes and family about warning signs and symptoms. Make sure
they know about sick day management and when to seek advice. Health professionals
should be aware of the appropriate management of people who are at risk.
Urinary Ketones 4+s on dip stick May be present but not relevant
Subsequent course Insulin therapy required in Ongoing insulin therapy often not
all cases required. May be required in the
long term.
! If the person is administering their own insulin, check their technique and
knowledge.
! On days of illness, usual medication must be taken with usual diet / supplements
and blood tested more frequently, eg 2 hourly. Extra medication may be required.
These guidelines apply when the person with diabetes is feeling unwell or noticing
signs of an illness and / or:
Type 1 diabetes
Type 2 diabetes
1. Stress to the person with diabetes the need to continue insulin or diabetes
medications.
Gastrointestinal illnesses may cause hypoglycaemia for individuals treated with
insulin, sulphonylureas or repaglinide. In this instance these medications may
need to be reduced according to blood glucose readings.
Type 1 diabetes
! stopping insulin when unwell is a very common mistake people make and a
key reason for development of ketoacidosis.
Type 2 diabetes
! metformin should be ceased with onset of intercurrent illness under the
guidance of a GP / MO.
2. Ask the person with diabetes to monitor glucose and ketones (if relevant)
more frequently.
Type 1 diabetes
! blood glucose two hourly or more frequently if low blood glucose or
significant ketones present.
! ketones two to four hourly when blood glucose is 15mmol/L or higher
and / or signs of illness (urine or blood ketone testing).
Type 2 diabetes
! blood glucose two to four hourly, more frequently if low blood glucose.
Rehydration solutions (eg Gastrolyte) can help to replenish fluid and electrolytes
loss through vomiting, diarrhoea or dehydrated. Rehydration solutions have a
relatively low concentration of carbohydrate therefore additional carbohydrate
may be required.
Type 2 diabetes
See table 2.
Table 2
Treatment Possible action
! No medication for hyperglycaemia. ! May require the addition of
sulphonylureas or insulin
temporarily.
! Treated with hypoglycaemic agents. ! If not on maximal dose of
sulphonylureas (only applies to
non-slow release) or glitinides
consider increasing.
! Increasing other hypoglycaemic
agents is not recommended.
! Treated with hypoglycaemic agents ! May require supplemental
and nocte basal insulin. quick acting insulin (see notes
below).
! Treated with mixed insulin. ! May require supplemental
quick acting insulin (see
notes below).
Variations to insulin dose percentage and monitoring that apply for type 2
diabetes (who have access to short acting insulin) are outlined below.
! Blood glucose >15mmol/L advise extra 10% of insulin dose and 2 hourly
monitoring.
! Blood glucose >22mmol/L advise extra 20% of insulin dose and 2 hourly
monitoring.
See table 3 (on next page) for supplemental insulin doses and management
strategies.
Note
Individuals with insulin pumps can develop ketosis and DKA more quickly
because there is no background reservoir of long acting insulin. Always check
for technical problems with the pump and advise use of pen or syringe for
supplemental insulin doses. General sick day guidelines for patients with an
insulin pump include:
! Increase the basal insulin rate by 20-50% during illness when the blood
glucose levels are elevated.
! Use the correction bolus feature of the insulin pump every 3-4 hours to
decrease blood glucose level to its target range.
! Early medical review is essential to ensure correct doses are delivered.
Further details should be sort from the persons specialist team. See
Hospitalisation Section 4 for more details.
Glucagon in small doses may prevent or treat mild hypoglycaemia in people with
gastroenteritis or reduced carbohydrate intake including children.
Note: Women who are pregnant are advised to seek medical help early if they are
sick.
This is a complex phenomenon that usually only occurs in type 1 diabetes. The
Somogyi effect may partly reflect the release of counter-regulatory hormones such as
glucagon, adrenaline, noradrenaline, cortisol, growth hormone stimulated by
hypoglycaemia. These hormones stimulate the release of stored glucose from the
liver, and also increase the manufacture of glucose by the liver. The persons
response to the hypoglycaemia episode may also contribute because people often eat
more than is required to treat the hypo.
Clinical Presentation
Management
Honeymoon phase
The `honeymoon phase is a term used to describe the period of time immediately
following initial diagnosis of type 1 diabetes.5 The beta cells may continue to produce
insulin for a further 6 to 18 months. Often less insulin is needed and hypoglycaemia
occurs. Young children occasionally require dilution of insulin because so little insulin
is needed. C-peptide blood tests reflecting the amount of insulin secreted by the
persons pancreas can determine the extent of endogenous insulin production.
Treatment of the dawn phenomenon requires additional insulin activity by either oral
hypoglycaemic agents or insulin therapy but at the same time ensuring hypoglycaemia
is avoided. It is also important to distinguish from the high fasting blood glucose levels
which could be a result of the Somogyi effect.
Management involves regular home blood glucose monitoring with extra monitoring at
3.00am to ascertain the blood glucose levels and to assist with medication
adjustments.
Lactic acidosis
Lactic acidosis is the accumulation of lactic acid in the body. The condition is rare and
generally occurs in the older person.
The risk of lactic acidosis increases where there is decreased tissue perfusion
associated with septicaemia or cardiovascular shock, or with alcohol abuse associated
with renal or hepatic impairment. It may be aggravated by metformin therapy.
Signs of lactic acidosis include deep and rapid breathing, vomiting and abdominal pain.
Metabolic acidosis is present but ketones are absent or minimal.
Macrovascular complications result from damage to major blood vessels and can
include:
! nephropathy
! retinopathy
! neuropathy.
In both type 1 and type 2 diabetes the microvascular and macrovascular complications
of diabetes substantially increase a persons morbidity and mortality. Two landmark
studies the Diabetes Control and Complications Trial (DCCT)1 and the United Kingdom
Prospective Diabetes Study (UKPDS)2 have demonstrated that a reduction in HbA1c
can substantially lower the risk of long term complications.
In 1993 the DCCT showed unequivocally in type 1 diabetes that lowering blood glucose
delayed the onset and slowed the progression of microvascular complications. These
risk reductions varied from 35 to 75% amongst the microvascular complications. A
reduction in macrovascular complications was seen but it did not reach significance
(this may have been due to the small numbers of complications seen in the time
frame). It was important to assess if these reductions would also be seen in type 2
diabetes and in 1998 the results from the largest and longest study on people with type
2 diabetes was published (UKPDS).2 The UKPDS results demonstrated that
retinopathy, nephropathy and possibly neuropathy are benefited by lowering blood
glucose levels. The overall microvascular complication rate was decreased by 25%.
As in the DCCT trial there was a reduction in cardiovascular complications but it did not
reach significance. The study showed that lowering blood pressure significantly
reduced strokes, diabetes-related deaths, heart failure, microvascular complications
and visual loss.2 The UKPDS was a landmark study which has resulted in a much
more aggressive approach to the treatment of hyperglycaemia, hypertension and other
associated risk factor reduction strategies.
Long term follow up of participants from the original DCCT and UKPDS groups
have demonstrated a legacy effect associated with achieving glucose targets
early in the course of diabetes even when this level of control is not maintained
some years
later.3, 4
! assist in educating the person about risk factors and indicators of long term
complications
! assist in early detection and monitoring of existing problems
! assist in the management of complications which may already be present.
Note: Our aim in this manual is to alert health care providers to the types of problems
which may occur. More extensive reading is required if you wish to study the
pathophysiology relating to long term complications.
Prevalence
In 2005, diabetes was listed as an underlying or an associated cause of death in
11,900 deaths (9% of all deaths in that year).5
Various forms of macrovascular disease tend to occur in the same individual. Thus
people with diabetes undergoing operations for peripheral vascular disease are at
special risk of peri-operative myocardial infarction or stroke. Assessment includes
checking for risk factors and indicators of macrovascular disease.
Management of risk factors will reduce the risk of developing macrovascular disease.
People with type 2 diabetes should be considered for prophylactic aspirin therapy
unless contraindicated.7
Early detection, active treatment and frequent review are essential if morbidity is to be
reduced. The treating medical officer / general practitioner should aim for lower blood
pressure levels in the person with diabetes because their blood vessels (both macro
and micro) are more susceptible to hypertension damage (eg "130/80).9 Non-
pharmacological treatment, especially maintenance of healthy weight, regular exercise
and minimisation of salt and alcohol in the diet, should be emphasised.
There are various anti-hypertensive agents which can be used to control blood
pressure, however there are some medications which may interfere with the control of
diabetes. Agents such as the angiotensin converting enzyme (ACE) inhibitors are
medications of choice in people with hypertension and diabetes.7 They do not affect
glucose metabolism or lipid profiles and have beneficial effect on renal and
cardiovascular function. Both lying and standing blood pressure must be assessed.
Angiotensin receptor antagonists (ARAs) have a role for people with micro or macro
albuminuria when ACE inhibitors are not tolerated.9
Hyperlipidaemia
Target Levels9
Total cholesterol <4.0mmol/L
Triglycerides <1.5mmol/L
HDL C >1.0mmol.L
LDL C <2.5mmol/L
There is evidence that minimal intervention in the general practice setting can improve
cessation rates. The diagnosis of diabetes is often a crisis point for the person, and
can be an opportunity to bring about cessation of smoking.
If a kidney problem is suspected and the presentation is atypical think of less common
problems related to diabetes eg papillary necrosis and arterial disease.
Damage affecting the retina responsible for control, colour and fine vision
(maculopathy) is the most common cause of visual loss in people with diabetes.
Other eye problems like glaucoma and ischaemic neuropathy are also more
common in people with diabetes.
Prevention is the most important aspect of management of the persons feet. Early and
regular screening of feet to assess potential abnormal architecture and regular review
of neuropathy, vascular disease or deformity is essential. Subsequent referral to
podiatry services for those people with at risk feet is imperative.15
! orthostatic hypotension
! impaired gastric emptying
! diarrhoea
! delayed / incomplete bladder emptying
! erectile impotence and retrograde ejaculation in males
! reduced vaginal lubrication with arousal in women
! loss of cardiac pain and silent ischaemia or infarction
! sudden, unexpected cardio-respiratory arrest especially under an anaesthetic or
treatment with respiratory depressant medications
! difficulty recognising hypoglycaemia.
Neuropathy associated with peripheral vascular disease is the major risk factor for foot
problems. Ulcers and infections which lead to amputation can be asymptomatic in
people who cannot feel their feet. Other risk factors for podiatric problems include:
Ulcers
The most common site for ulceration is the plantar surface of the foot, directly under
the metatarsal head. Abnormal shearing forces (such as movement within a shoe) can
cause a bruise under the epidermis. Infection then intervenes; the overlying skin or
callus becomes necrotic, sloughs and reveals an ulcer. Complications include cellulitis,
thrombotic arterial occlusion and gangrene.
If the ulcer is deep, or if cellulitis is present, hospitalisation and bed rest are usually
necessary. Subsequent antibiotic treatment and appropriate diabetes management will
be required. Inappropriate management of an ulcer can lead to osteomyelitis and
amputation. A podiatrist, endocrinologist and vascular surgeon should be involved in
the care and management of the acute diabetic foot.9
If ulcer is not infected and is superficial, care can be ambulatory. Only health
professionals who are experienced at managing diabetic foot ulcers or a podiatrist
should remove excess callus from around the ulcer to facilitate drainage. The person
should be encouraged to keep pressure off the lesion as much as possible to
encourage wound healing. Continual pressure on the surface of an ulcer can cause
delayed healing. Consult a podiatrist for advice about footwear modification to alleviate
pressure.
Sexual function
It is important to inquire about this in the annual screening because the prevalence in
men over 40 years old with diabetes may be as high as 50%.9
The help of a sympathetic specialist urologist should be sought for those considering
penile injection with vasoactive agents (preparations now commercially available) or
surgical treatment.
Women with diabetes do not seem to suffer from as much sexual dysfunction as men.
Some women with diabetes complain of impairment in vaginal lubrication with arousal,
presumably due to pelvic autonomic neuropathy. Explanation and use of lubricants
may be useful.
Thrush
Poor glycaemic control predisposes to refractory moniliasis (thrush). Other
predisposing factors include the oral contraceptive pill and antibiotic therapy.
Urine infections
Urinary tract infections are more common and more refractory, especially in women
with diabetes. Incomplete bladder emptying may contribute and may require drug or
surgical therapy. Urinary tract infections may be asymptomatic and should be looked
for especially in women (eg by a dipstick testing for blood, pyuria and bacteriuria).
Skin infections
High blood glucose levels and glycosuria encourage the growth of monilia (thrush) and
a number of bacteria (especially staphylococci). Often these infections persist until
blood glucose levels are controlled.
Refractive changes
Can occur because of high blood glucose levels.
Cataracts
Can occur because of long term osmotic effect on the lens.
Your feet
! Have your feet checked every six months. The health professional should check the skin,
pulses and sensation in your feet. Remember to wear shoes and socks that are easy to
take off.
! Know if your feet are at risk and have a footcare action plan.
Your teeth
! Visit your dentist regularly to ensure any existing problems are treated immediately.
! Learn how to take care of your mouth, gums and teeth.
! Tell your dentist you have diabetes.
Pathology tests
Become interested in the tests ordered by your doctor, and know your numbers.
Common ones are:
! Glycosylated haemoglobin
This test is usually done 3-4 times a year and shows your overall blood glucose control
over the past three months. Target is less than 7%.
! Cholesterol
Have this measured every year. High cholesterol is a risk for heart attacks (coronary
artery disease) and circulation problems. Total cholesterol target is less than 4.
! Microalbuminuria
First morning urine collected and done each year.
7. National Health & Medical Research Council (2004) Part 5: Prevention and
detection of macrovascular disease in type 2 diabetes. Evidence based
guidelines for case detection and diagnosis of type 2 diabetes. NHMRC,
Canberra.
10. Litt J (2002) How to provide effective smoking cessation advice. Australian
Family Physician, 31(12): p1-7.
11. Litt J, Ling M-Y, and McAvoy B (2003) How to help your patients quit: Practice-
based strategies for smoking cessation. Asia Pacific Family Medicine, 2: p175-
179.
13. Australian Diabetes Society (2008) Guidelines for the management of diabetic
retinopathy, NHMRC and Department of Health & Ageing, Canberra.
15. National Health & Medical Research Council (2005) Part 6: Detection and
prevention of foot problems in type 2 diabetes. National evidence based
guidelines for the management of type 2 diabetes mellitus. March, NHMRC,
Canberra.
Regardless of the type of maternal diabetes, babies of women with diabetes are at an
increased risk of intrauterine death, macrosomia (causing difficulties with delivery),
neonatal respiratory distress syndrome, neonatal hypoglycaemia, jaundice and
others.2, 3
We recommend that health care professionals who work with women who are pregnant
and have diabetes become familiar with two key documents:
2. Gestational diabetes.
Before pregnancy
All women with type 1 and type 2 diabetes should receive counselling and
information about potential problems of diabetes in pregnancy, the potential
dangers of an unplanned pregnancy, and the benefits of pre-pregnancy
counselling.4
Women with pre-existing diabetes should plan their pregnancy. They should have their
HbA1c monitored and obtain tight control prior to and during early conception, noting
that careful management should aim to prevent severe maternal hypoglycaemia. The
ideal HbA1c preconception is less than 6.1%. Less than 7.0% is satisfactory and 7.0%
to 8.0% is borderline. An HbA1c greater than 8.0% is not satisfactory and should be
tightened before conception, and those with HbA1c greater than 10.0% should be
advised of their extreme risk should they get pregnant.7
Folic acid 5mg daily should be commenced to minimise the risk of folate
deficiency induced birth defects.
Management of diabetes in the preconception phase aims to ensure the best outcome
for both mother and baby. Questions that might arise include fertility, spontaneous
abortion, incidence of diabetes mellitus in offspring, effects of pregnancy on existing
diabetes complications and expected outcomes. These questions should be
addressed in a supportive manner to reduce anxiety.
Healthy nutrition is important for all pregnant women (see Healthy eating Section 8).
Energy and nutrient requirements must be individualised. However, it is recommended
that all women with diabetes be assessed by a dietitian and advice given on
appropriate meal planning.
Women with type 2 diabetes may also be taking antihypertensive or lipid lowering
medications. Consideration needs to be given to ceasing angiotensin converting
enzyme inhibitors and angiotensin receptor blockers prior to pregnancy, because of
their potential for teratogenesis. This may need to be balanced with the need to
preserve maternal renal function until pregnancy is established11. Lipid lowering
medication is contraindicated in early pregnancy4. In neither case, the risks to the fetus
are not sufficient to warrant termination of pregnancy.
Women on oral hypoglycaemic drugs are generally advised to switch to insulin therapy
before they conceive4 6. If a woman on oral hypoglycaemic agents becomes pregnant
whilst taking oral hypoglycaemic drugs, then insulin can be commenced with a slow
withdrawal of oral treatment so that diabetes control can still be maintained during this
transition period. An abrupt stopping of oral therapy can lead to poor diabetes control
which can have adverse effects during pregnancy4.
The pregnancy is monitored the same as other pregnancies with an extra scan at
around 32-34 weeks to check foetal growth should be considered.
Labour
Obstetric assessment is essential in determining the mode of delivery. Encourage
women to discuss their delivery plans with the obstetrician early in the pregnancy.
Delivery should be at term unless obstetric or medical factors dictate otherwise4.
Often women are advised to continue taking their usual insulin until the start of labour
or until they commence fasting for a caesarean. At this point the woman would
commence an insulin/glucose infusion protocol. Each hospital should have its own
protocol for management during and post labour. The goal during labour is to provide
adequate carbohydrate intake to meet maternal energy requirements and to maintain
euglycaemia.
After delivery
Mother
Following delivery, insulin requirements of women with pre-existing diabetes decrease
before returning to around pre-pregnancy requirements (this time is variable and can
take days). If fasting the woman will require a glucose infusion and the hospital
protocol needs to account for the unpredictability of the blood glucose levels. The
woman has an increase in insulin sensitivity (ie reduced insulin requirements) and
consequently hypoglycaemia risk is increased during this period.
Baby
The baby must be monitored for hypoglycaemia during the first 24 hours. Each
hospital should have an agreed protocol to guide the care of the baby. The
paediatrician or medical officer (MO) will assess and manage post delivery
complications.
If the OGTT is negative repeat 75gm OGTT at 24-28 weeks. If a woman vomits during
the OGTT an option is to do 2 weeks of home blood glucose monitoring instead of
repeating the OGTT. The woman can be asked to test fasting and 2 hour post prandial
at breakfast, lunch and tea. If the fasting BGL is above 5.5mol/L or the 2 hour post
prandial is above 7.8mmol/L then they can be classified as having gestational diabetes.
9
Management
All women should receive individual education, counselling and specific dietary advice
from a diabetes educator, a dietitian and a medical consultant.
Women are taught self blood glucose monitoring and in some services are loaned a
blood glucose meter. The diabetes educator should make arrangements for the
woman to make contact with them on a one to two weekly basis (either by phone or
face to face). Women should have access to a dietitian as needed. Technique and
accuracy of blood glucose testing should be regularly checked.
Aim of treatment
Management of the pregnancy is as for pre-existing diabetes. The mainstay of
treatment is a healthy diet with regular intake of carbohydrates. If diet alone does not
control blood glucose levels, then insulin is commenced.
The overall aim of treatment is to maintain fasting blood glucose values less than
5.5mmol/L and less than 7.0mmol/L 2 hours post prandial. Insulin therapy is started if
fasting blood glucose values exceed this more than twice in a one to two week interval.
The women should have access to 24 hour phone support for any problems from the
diabetes and obstetric services or obstetric registrar.
Labour
Spontaneous labour at term should be considered for those whose blood glucose
levels have been optimal throughout and whose pregnancy is clinically uncomplicated
(eg no pre-eclampsia, hypertension, poor glycaemic control, foetal growth, amniotic
fluid abnormalities on ultrasound, urinary infections or other infections). However, a
woman should not go beyond full term. The obstetrician will arrange for an
interventional delivery at 38 weeks if required.
After delivery the need for insulin therapy usually ceases. It is recommended that each
hospital adheres to an agreed protocol for the assessment of blood glucose levels.
First 3-4 hours post Hourly blood glucose levels if To monitor hypoglycaemia
partum5 glucose/insulin infusion in patients who have
ceased insulin therapy
Women are encouraged to breastfeed as this assists blood glucose and weight control
in addition to all the normal benefits of breastfeeding.
All women who have had gestational diabetes should be counselled about the life long
risk of developing type 2 diabetes and the need for yearly follow up.
Monitoring
There is no need for ongoing self-monitoring if the womens blood glucose level is
normal after delivery. Women should know that the symptoms of polyuria, polydipsia,
polyphagia, thrush and blurred vision may indicate the development of type 2 diabetes.
Women who have had gestational diabetes should have 1 yearly blood tests done to
assess for diabetes.5
Subsequent pregnancies
Women should be counselled as to the risk of GDM in subsequent pregnancies and/or
development of type 2 diabetes prior to any subsequent pregnancy. Pre-conception
screening and earlier screening in pregnancy (13-14 weeks) is advised. A healthy
lifestyle is to be encouraged between pregnancies.
Contraception
It is very important to discuss contraception with all women postnatally. Women
should discuss the most appropriate option with their GP or specialist physician.
Women who have gestational diabetes need to be informed that they should visit their
GP for preconception diabetes screening prior to stopping contraception. Women with
pre existing diabetes should plan any subsequent pregnancies with their GP or
specialist physician prior to stopping contraception.
9. Jeffries Bill (Lyell McEwin Hospital) (2009) Screening for gestational diabetes:
Personal communication. Diabetes Outreach, Adelaide.
Australias aged care system is structured around two main forms of formal care delivery,
residential and community care. Residential care facilities function to either provide services, or
provide access to services. These services range from nursing homes and hostels to
retirement villages for older people.
Other alternatives can include temporary homeless shelters, homes for the mentally ill, homes
for the mentally challenged, homes for the disabled, respite services, in-home care or home
care community services. For more information about aged care services, go to
www.agedcareaustralia.gov.au.
For people who have any type of diabetes, the consequences of not receiving adequate
treatment and care can be devastating. Long standing uncontrolled diabetes places the person
at risk of short and long term complications.
In the short term, uncontrolled blood glucose can cause confusion, sleep disturbances,
incontinence and thrush. Low blood glucose can worsen the risk of falls.
In the long term, uncontrolled diabetes affects the heart and other major blood vessels, eyes,
kidneys, feet and nerves, causing disability and loss of quality of life. It also contributes to the
worsening of existing complications.3
Given the persons age, mobility, mental capacity, the potential to reduce some risks may be
limited. Nevertheless, risk factor identification is an important aspect of primary prevention for
both type 2 diabetes, cardiovascular disease and kidney disease.
Diagnosis
A diagnosis criterion is based on the Royal Australian College of General Practitioners
Guidelines6, and can be found in Understanding diabetes Section 2 of this manual.
Cycle of care
Residents with diabetes have a right to an individualised diabetes management plan. This plan
should take into account the persons age, functional mobility and cognitive capacity.
If residents are cared for by a general practitioner, they will be eligible for either a GP
Management Plan and / or a Team Care Arrangement. These items will facilitate access to
specialist health professionals such as diabetes educator, podiatrist and dietitian.
A cycle of care for a person with diabetes includes routine monitoring of:6
! blood pressure
! height/ weight/waist BMI
! feet examination
! glycaemic control (HbA1c)
! blood lipids
! microalbuminuria
! eye examination
! smoking
! healthy eating plan
! physical activity
! self-care education.
Depression can result in a loss of meaning in life and a decrease in positive behaviour.
If any of the above are noted or of concern it is important to seek advice from senior staff or the
persons general practitioner.
Hypoglycaemia
As part of the ageing process there is reduced glucose counterregulation and this can decrease
the awareness for hypoglycaemia. Increased blood glucose monitoring may be required to
detect unrecognised hypoglycaemia.10 Refer to Understanding diabetes Section 11 for more
information
Hyperglycaemia
It is important to consider the possibility of hyperosmolar hyperglycaemic nonketotic state for
those with type 2 diabetes and ketoacidosis for those with type 1 diabetes, if the older person
has extremely high glucose levels.10 Refer to Understanding diabetes Section 11 for more
information.
Staff training
All staff (RNs, ENs and carers) should have access to training about the needs of a person
with diabetes (all types of diabetes) and be aware of the risks of developing type 2 diabetes.
Training should include awareness of the criteria for diagnosis, primary prevention strategies,
risk screening and cycle of care for management of diabetes. Possessing the necessary
knowledge and skills to respond to acute presentations of hypoglycaemia and hyperglycaemia
in a competent and timely manner is paramount in order to prevent further deterioration and
possible hospitalisation.
Other aspects such as medication management, foot and dental care, healthy eating and
suitable activity are also important to maintain a level of desirable wellness.
It is also important to include information about the psychosocial aspects of diabetes and the
impact this can have on the individual and their family.9 Developing links with the local /
regional diabetes education team can provide support and advice re training opportunities.
Virtual teams
Teams dont have to be located together in the same building or health service. The use of
virtual teams will enable organisations to develop appropriate networks utilising telephone, fax
and email. A diabetes educator is one member of this team that can help staff learn how to
better care for people with all types of diabetes.
Organisational responsibility also extends to the provision of appropriate policy and procedure
being in place. These policies and procedures more commonly cover care issues such as cycle
of care, blood glucose monitoring, medications including administration of insulin,
hypoglycaemia and hyperglycaemia and sick day management
Refer to other sections of this manual to assist with policy and procedure development.
It is extremely important to consider the staffing and training needs of the organisation to ensure
all levels of staff possess an acceptable level of competency. Also consider what policies and
procedures will need to be in place to ensure a safe environment for the resident.
3. Australian Diabetes Educators Association (2003) Guidelines for the management and
care of diabetes in the elderly: Report. Australian Diabetes Educators Association,
Canberra.
5. Diabetes Australia (2005) Tick Test. [Cited 15 June 2009]; Available from:
http://www.diabetesaction.com.au/diabetesaustralia/display.asp?entityid=4081
7. Sinclair AJ (2006) Special considerations in older adults with diabetes: Meeting the
challenge. Diabetes Spectrum, 19(4): p229-233.
8. Suhl E and Bonsignore P (2006) Diabetes self-management education for older adults:
General principles and practical application. Diabetes Spectrum, 19(4): p234-240.
9. DAWN (Diabetes Attitudes Wishes Needs) Study (2001) Living with diabetes. [Cited 14
June 2009]; Available from:
http://www.dawnstudy.com/documents/home_page/document/index.asp
10. Australian Diabetes Educators Association (2003) Guidelines: Management and care of
diabetes in the elderly: Summary. ADEA, Canberra.
11. BeyondBlue (2009) Depression checklist: Kessler psychological distress scale (K10).
[Cited 15 June 2009]; Available from:
http://www.beyondblue.org.au/index.aspx?link_id=103.882
12. Diabetes Centre (2007) Healthy eating and diabetes: A guide for aged care facilities.
Diabetes Centre, Adelaide.
For further information contact a Diabetes Australia office on 1300 136 588 (local call
cost).
Diabetes Australia
Diabetes Australia is the national coordinating organisation representing consumers (people
with diabetes), research organisations, doctors and other
health professionals with a special interest in diabetes.
Diabetes Australia administers the National Diabetic Services Scheme (NDSS) which
offers subsidised prices for reagent strips, free syringes and needles and subsidised
insulin pump consumables to Australians with diabetes. Diabetes Australia also has a
comprehensive range of approved, educational material on diabetes management.
! Friendly, knowledgeable staff willing to assist with questions and enquiries about
diabetes or refer you to appropriate health professionals.
! A comprehensive range of brochures and diabetes information sheets to assist in
managing diabetes.
! A quarterly publication, CONQUEST which focuses on medical articles and
research of professional note.
! Arranging annual camps for children and parents and children to assist with
diabetes management and education.
! A lobby group presenting the views of people with diabetes to government.
! Seminars and information days held throughout the year on a variety of topics to
help people with their diabetes management.
National Office:
Level 2 103-105 Northbourne Ave
TURNER ACT 2612
Telephone: (02) 6232 3800 Fax: (02) 6230 1535
Name Telephone
Modbury Hospital
Smart Road, Modbury SA 5092 (08) 8161 2000
Private
Ashford Community Hospital
(08) 8375 5222
55 Anzac Highway, Ashford SA 5035
Western Hospital
(08) 8356 1222
168 Cudmore Terrace, Henley Beach SA 5022
Wakefield Region
Angaston 8564 2996 Barossa CHS
Clare 8842 6555 Lower North CHS
Gawler 8521 2000 Gawler Health Service
Minlaton 8853 2380 York Peninsula HS
Wallaroo 8823 3122 Wallaroo CHS
Yorketown 8852 1200 Yorketown HS
Riverland Region
Berri 8580 2500 Riverland Regional HS
Broken Hill
Broken Hill 8088 5441 Regional Diabetes Centre
Support / psychological
Relationships Australia provides courses that develop self-understanding, self-
confidence and skills in communication, assertion and stress management for
teenagers and adults. The Relationships Australia Bookshop has a wide range of
books dealing with human relations and self development. A lending library service is
also available. For more information, contact:
Professional organisations
! Australian Diabetes Educators Association
! Dietetics Association of Australia
! Australian Podiatry Association
! The Australian Nutrition Foundation
! National Heart Foundation
! Australian Kidney Foundation
! Exercise Physiologists
! Psychology Association
National Diagnostic Products (Aust) Pty Ltd Telephone: (02) 9432 8100
Unit 22, 39 Herbert Street
St Leonards NSW 2065
acetone a chemical (see ketone bodies) formed when the body breaks down fat
instead of glucose for energy. Levels rise and acetone spills into urine and is exhaled
in the breath producing a fruity smell.
alpha cells cells in the pancreas that produce the hormone glucagon.
anabolism the constructive growth and repair phase of metabolism within the body
cells.
auscultation listening for sounds within the body, chiefly to ascertain the condition of
the thoracic or abdominal viscera and to detect pregnancy.
background retinopathy an early stage of diabetic retinopathy that usually does not
impair vision also referred to as non-proliferative retinopathy.
carbohydrate (CHO) one of the main food groups which provides an immediate
source of energy for the body. Carbohydrates which include sugars and starches are
digested into simple sugars such as glucose. Carbohydrates are stored as glycogen.
dawn phenomenon the early morning (4am 8am) rise in blood glucose level.
diabetes insipidus a disease of the pituitary gland not diabetes mellitus. Often
known as water diabetes due to a deficient quantity of anti-diuretic hormone being
released or produced resulting in failure of reabsorption of water from the renal
tubules.
Type 1 accounts for 10-15% of all types of diabetes mellitus. Its clinical onset
is sudden and usually occurs in people under the age of 30 but can occur at
any age. This type of diabetes is dependent on injections and exogenous
insulin as there is an absolute insulin deficiency.
Type 2 has an onset which is insidious and usually occurs in people over 40
years of age but is becoming more common in the younger age group. It is
characterised by a relative deficiency of insulin and resistance to insulin action.
dialysis artificial removal of waste products from the blood when the kidneys fail.
Doppler instrument a device for measuring blood flow within an artery or vein.
Sound waves are reflected by the moving red blood cells back towards the transducer.
The sound is proportional to the velocity of blood flow. It is used in assessment of
vascular status and abnormalities in major arteries and veins.
dorsalis pedis the pulse on the upper outer part of the foot.
endocrine glands glands that produce chemicals (hormones) which affect other
body cells.
endogenous grown or made inside the body. Insulin that is made by the persons
own pancreas is endogenous.
exchanges servings of food that contain the same food value. Also known as
portions.
exogenous grown or made outside of the body. Insulin that is manufactured from
animal pancreas or genetically engineered is exogenous insulin.
flourescein a harmless yellow coloured dye that is used to outline the vessels of the
eye.
gastroparesis a form of neuropathy that affects the stomach. Digestion of food may
be incomplete or delayed, resulting in nausea, vomiting or bloating which makes blood
glucose control difficult.
glomerular filtration rate measure of the kidneys ability to filter and remove waste
products.
glomerulus a tiny tuft of blood vessels that is part of the functional unit of the kidney.
glucose tolerance test a diagnostic test for diabetes involving a drink of glucose
(after an overnight fast) followed by a series of blood glucose estimations over 2 hours.
glycogenesis the conversion of glucose into glycogen for storage in the liver.
glycogenolysis the breakdown of glycogen into glucose in the liver when blood
glucose levels are very low.
hyperinsulinemia a condition in which the level of insulin in the blood is higher than
normal. Caused by overproduction of insulin in the body. Related to insulin
resistance.
hypoglycaemia abnormally low blood glucose levels of less than 4mmol/L. A risk for
people who require medication to control diabetes.
impaired fasting glucose (IFT) describes a condition in which blood glucose levels
are moderately elevated but not elevated to the range diagnostic of diabetes mellitus.
Fasting blood glucose is found between 5.5 and 6.9mmol/L. See pre-diabetes.
impotence the inability to get or maintain an erection for sexual activity. Also called
erectile dysfunction.
insulin is a hormone that is secreted by the beta cells of the pancreas and is the
major fuel regulating hormone. Insulin is secreted in response to a rise in blood
glucose and facilitates the utilisation of glucose by the cells. Insulin enables the
transport of glucose across the cell membrane. Insulin is responsible for the storage of
glucose and amino acids, increases protein and fat synthesis and inhibits the
breakdown of fat.
insulin basal rate a steady trickle of small amounts of *ultra-short acting insulin
used in insulin pumps.
insulin bolus an amount of insulin taken to cover an expected rise in blood glucose,
often related to a meal or snack.
insulin resistance the bodys inability to respond to and use the insulin it produces;
may be linked to obesity, hypertension, and high levels of fat in the blood.
ischaemia a deficient blood supply to part of the body due to constriction or actual
obstruction of a blood vessel.
islet cell autoantibodies (ICA) proteins found in the blood of people with newly
diagnosed type 1 diabetes. They are also found in people who may be developing
type 1 diabetes. The presence of ICA indicates that the bodys immune system has
been damaging beta cells in the pancreas.
islets of Langerhans a group of cells in the pancreas that make and secrete
hormones. Beta cells make insulin. Alpha cells make glucagon. Delta cells make
somatostatin.
lactic acidosis a serious condition caused by the build up of lactic acid which is
produced from glucose when there is not enough oxygen. Similar effects as
ketoacidosis.
lipoatrophy atrophy of the subcutaneous tissue which may occur at injection sites
due to poor injection techniques.
lipohypertrophy lumps that may occur at injection sites due to poor injection
technique and over use of the site of injection.
lypodystrophy lumps or small dimples seen on the skin of people using insulin
injections. The cause is due to poor injection technique or not rotating the injection site
and then over using the same injection area and/or administering cold insulin.
macrosomia greater than normal bodily size. In full term babies this is determined
by birth weights greater than 4.4 kilograms.
metabolism the physical and chemical processes and reactions taking place among
ions, molecules and atoms in the body. The utilisation of nutrients following digestion.
microvascular disease a disease of the smallest blood vessels. The walls of the
vessels become thickened and weak which results in blood and protein leakage or
blockage.
oral hypoglycaemic agents (OHAs) medications taken by mouth that stimulate the
release or improve the action of insulin:
biguanides reduces the amount of glucose produced by the liver and helping
the body respond better to the insulin made in the pancreas.
pancreas an elongated gland that lies in the abdomen posterior to the stomach and
partially surrounded by a loop of the small intestine. Its exocrine function is to produce
and secrete digestive enzymes. The endocrine function in relation to diabetes is to
produce and release insulin and glucagon.
pedal pulses arterial pulses which can be palpated on the dorsum (dorsalis pedis)
and medial site (posterior tebial).
post prandial blood glucose the blood glucose level taken 2 hours after eating.
pre- diabetes a condition in which blood glucose levels are higher than normal but
are not high enough for a diagnosis of diabetes. People with pre-diabetes are at
increased risk for developing type 2 diabetes and for heart disease and stroke. Other
names for pre-diabetes are impaired glucose tolerance and impaired fasting glucose.
pruritus itching.
pyelography x-ray of the kidney and ureter after injection of a contrast medium.
serum osmolality a measure of the number of dissolved particles per unit of water in
serum.
uremia the illness associated with a build up of urea in the blood because the
kidneys are not working effectively. Symptoms include nausea, vomiting, loss of
appetite, weakness and mental confusion.