The Patient/Client With Diabetes Mellitus
Upon completion of this chapter, the nurse will:
1. Summarize the difference between type 1 and type 2 diabetes mellitus
2. Examine approaches to assess diabetes mellitus
3. Determine strategies to aid the patient/client with diabetes mellitus
TYPES OF DIABETES MELLITUS
A complete review of diabetes mellitus is beyond the intention of this text. Rather, a brief review of the types of diabetes will be provided along with anticipated or expected effects if the disease is not adequately managed.
Type 1 diabetes mellitus is caused by destruction of the beta cells (islets of Langerhans) in the liver. The body does not produce insulin, a hormone for which a continuous supply is required. At one point, it was believed that type 1 diabetes mellitus was a disease of childhood. Through ongoing research, it was discovered that anyone at any age can develop this type of diabetes.
Type 2 diabetes mellitus is caused by insulin resistance. The body has been making insulin in response to dietary intake that, over time, causes the beta cells to become fatigued. In addition, the body ceases to recognize or use available insulin in the tissues. This form of the disease is considered the most prevalent and can also occur at any age. In the past, type 2 diabetes mellitus occurred most often in middle age but is increasingly being diagnosed in preadolescent children.
The major complication of type 1 diabetes mellitus is diabetic ketoacidosis (DKA), whereas the major complication for type 2 diabetes mellitus is hyperosmolar hyperglycemic state (HHS). In both conditions, the blood glucose levels are wildly elevated and cause tremendous adverse effects. Additional manifestations of these complications are as follows:
Manifestations of DKA
Manifestations of HHS
Dry mucous membranes
Altered level of consciousness
Nausea and vomiting
Ketone breath odor
Excessive urine output
Further complications of diabetes mellitus are categorized as being either macrovascular or microvascular. Macrovascular complications include:
Coronary artery disease
Peripheral vascular disease
And microvascular complications are:
Even though diabetes affects all body organs, it causes the most harm to the blood vessels, the eyes, the kidneys, and peripheral nerves. It is because of these complications that individuals with either type of the disease should be counseled to have:
Routine eye examinations
Annual assessment of urine albumin levels
Routine assessment of blood pressure
Frequent examinations of the feet
GENERAL TELEPHONIC CARE NEEDS
One of the first telephonic disease management programs was for diabetes, and these programs continue today. It has been found that, for people with diabetes, telephonic care reduces the onset of macro- and microcomplications and subsequent hospitalizations.
The purpose of contacting people in these programs is to reinforce their prescribed treatment plan. In general, the major categories when providing care are:
Patients/clients are instructed to perform capillary blood glucose testing at various times. As a telephonic nurse, you need to first find out how frequently the testing is being done. Oftentimes, clients receive the monitors as a service from different pharmaceutical companies; however, the supplies to use the monitors (strips, reagent liquid) can be costly. Before encouraging a client to increase capillary testing, listen to how the client responds to the expected frequency. For example, if the client says “those strips are so expensive so I only test once in the morning,” encouraging the client to increase the frequency of the testing will not be productive.
Urine testing for ketones and glucose may be done by some clients with type 1 diabetes mellitus; however, it is not widely used for those with type 2.
At one point, insulin was reserved to treat individuals with type 1 diabetes mellitus, and oral agents were used to treat those with type 2 of the disease. This is not the case anymore. Although the only treatment for type 1 diabetes mellitus is insulin, those with type 2 may be treated with either oral agents, insulin, or both.
When assessing medications, be sure to correctly document the type of insulin being used and the amount in units. Your care regarding insulin use should focus on:
Ability to fill syringes
Ability to self-administer doses
Identification of appropriate injection sites
Avoidance of hypertrophy or atrophy of subcutaneous tissue
Appropriate timing of injections (based on the type of insulin used)
New oral agents to treat type 2 diabetes mellitus are constantly being developed. The most recent classifications for these medications with examples are:
Glyburide (DiaBeta, Micronase)
Synthetic amylin hormone
Assessing current medications includes the name, dose, and frequency being taken.
One noninsulin medication used to treat type 2 diabetes mellitus is injected; however, it is not insulin—it is the incretin mimetic exenatide (Byetta). It is injected before the morning and evening meals; never after a meal.
For some clients with diabetes, dietary management can be the most challenging aspect of self-care. Many years ago, people with diabetes were handed a diet to follow in order to control blood glucose levels. As research in the disease progressed, the philosophy of following a strict diet has decreased to be replaced with eating plans that support the client’s preferences while controlling the intake of carbohydrates.
Weight management is often included in the treatment plan for those with type 2 diabetes mellitus. At times, losing a predetermined percentage of body weight has helped reduce the need for medication to treat the disorder. This approach is not successful for all clients with the disease.
A client with this disorder might ask you to “send a diet” to follow to help control blood glucose levels. Because this is rarely if ever done, the client may benefit from discussing meal planning with a nutritionist or dietitian. Should a client be provided with an eating plan from a health care provider, ask the client to tell you the daily calorie intake and number of carbohydrate servings per day. This information is helpful to have available for future care calls.
Activity and Exercise
Individuals with diabetes are encouraged to maintain and often increase their activity level. Inactivity has been found to contribute to increased body weight and the onset of type 2 diabetes mellitus. Before promoting any particular physical activity, assess the patient/client for current activity status. There are many online tools that subdivide activity status into categories such as sedentary, light activity, moderate, and heavy activity. A good starting point might be to ask what type of employment the client engages in. Then you can ask what type of physical activity the client routinely participates in, such as walking the dog every morning and evening, swimming at the local health facility, or playing tennis or golf on the weekends. You might find that some older clients spend the vast majority of the day sitting. For these individuals, exercise might be walking up and down the steps in the home several times a day or walking to the mailbox. Another suggestion might be to walk in a grocery store or shopping mall if inclement weather is a factor. Not every client is able or capable of engaging in an outdoor walking program. And, depending on where the client lives and socioeconomic status, joining a health facility or club may not be an option.
Remember that an activity or exercise program should not be encouraged unless it is supported by the health care provider. The client will most likely state that “my doctor told me to get more exercise” or “I was told I have to move more if I expect to lose weight.” These comments indicate that the health care provider has discussed physical activity with the client.
Although the client may be measuring capillary blood glucose values daily, the hemoglobin A1c blood test is considered the gold standard when evaluating the success of glycemic control. This test determines the average blood glucose levels over the previous 6 to 12 weeks and is typically measured every 3 months. Each client’s goal for the hemoglobin A1c will be determined by the health care provider.
Additional tests will most likely be prescribed to determine the development or presence of macro- or microcomplications. These diagnostic tests include:
Urine albumin level
Serum blood urea nitrogen