This site is intended for health professionals only

Practice nursing fundamentals - diabetes

Paul Sheldon
LRCP MRCS
Director
DTC Primary Care Training Centre
Bradford

Diabetes is defined as a state of chronic hyper-glycaemia. In the past the cause was put down to failure of the beta-cells of the islets of Langerhans in the pancreas to produce sufficient insulin. This is the case in what is known as type 1 diabetes. However, in type 2 diabetes the beta-cells produce as much if not more insulin than in the non-diabetic, but it does not seem to work - the body seems to be "insulin-resistant".(1)
It now seems clear that type 1 and type 2 diabetes are different disease processes. Type 1 usually affects the younger person, its onset is acute and insulin ­injections are required to sustain life. The patients are often managed in secondary care, at least in the acute phase, as they are prone to both dangerous ketoacidosis and hypoglycaemia.
Type 2 diabetes usually occurs in older, heavier people, often with a family history of diabetes. The onset is less acute and treatment is through diet or medication. The medication may either stimulate the pancreatic cells to produce insulin (sulphonylureas such as gliclazide and glibenclamide), or help the insulin to work more effectively (metformin and the newer glitazone class of drugs). Insulin may be required for type 2 but the patient does not die if it is not given, and they are much less likely to suffer the extremes of ketoacidosis or hypoglycaemia. However, there is a high risk of coronary heart disease, and this is the main reason why type 2 diabetes is treated so seriously.(2,3) Patients with type 2 diabetes are frequently managed solely in primary care as the ­condition is perceived as being (although it is not) a milder form of diabetes.

Management
Managing diabetes in primary care is now usually ­carried out in a mini-clinic, which is organised at ­regular times, often once a week or once a fortnight depending on the size of the practice. There is an increasing tendency for these clinics to be nurse-led, following in the footsteps of asthma where this has been the norm for several years. The nurse running the clinic is normally trained to diploma level in the ­primary care ­management of diabetes.
Until very recently, the main aim of the mini-clinic has been to attain good control of blood sugar levels. These are normally assessed by estimating the HbA(1C) level. Normal adult haemoglobin is gradually ­"glycosylated" from HbA to HbA(1) at a rate depending on the level of blood sugar. The test effectively gives an average blood sugar level for the previous 6-8 weeks. The aim is an HbA(1C) level below or as near as possible to 7%.(4)
A further aim is to monitor for the traditional complications of diabetes - these affect the eyes (retinopathy), kidneys (nephropathy) and feet (neuropathy and peripheral vascular disease). The development of these complications seems to depend very much on glycaemic control. However, the emphasis is now changing rapidly towards the prevention of ­coronary heart disease through risk assessment and the management of blood pressure, lipids and lifestyle.
More advanced practices are increasing the scope of their diabetic clinics to include patients at major risk of coronary heart disease, even if they do not have diabetes.

The mini-clinic
The organisation of the mini-clinic has not changed much over the years, although there has been a change of emphasis.(5)
It is important that the clinic is organised at a time when the people involved have no other conflicting duties. Appointments are usually for 15-20 minutes, with the longer time being the optimum to provide information and education, especially in the matters of lifestyle and medication. The latter is becoming a major issue as the majority of middle-aged people with diabetes may require multiple medications to attempt to modify their risk of coronary heart disease. Typically, a patient could be on one or two medications to control blood sugar levels, two or three to control their blood pressure, one to control lipid levels and low-dose aspirin.
Patients normally attend the clinic every six months. The first consultation is fairly simple - the nurse will check for possible complications, as well as taking weight, blood pressure and HbA(1C) measurements, and offering further education. The second six-month appointment is usually called the annual review - this time the patient undergoes biochemical tests and eye, foot and dietetic checks. It is very useful if the podiatrist and dietitian can attend at the same time as it saves the patient several journeys to the surgery.
If possible, arrangements should be made to have an up-to-date HbA(1C) estimation available at the time of this consultation. A portable machine to carry out this test is available (Bayer Diagnostic DCA2000) and is extremely accurate, although most centres have to send the sample off to the laboratory. The best option would be to bring the patient into a preview clinic a week before the main consultation. Blood can be taken for the HbA1C estimation and other tests can be performed as required, such as a fasting lipid profile and serum ­creatinine, which are normally performed annually. The results will then be to hand at the actual consultation.
The main aims of diabetes management seem quite simple - to keep the HbA(1C) below or as near to 7% as possible, to reduce the blood pressure to 130/80mmHg, and to reduce the serum cholesterol level to below 5mmol/l.(6) However, to achieve these aims in a middle-aged, slightly obese, sedentary type 2 diabetic is far from easy. It is useful to remember that a 50-year-old person with diabetes and only modestly raised blood pressure and cholesterol levels has at least a one in three chance of suffering a heart attack within the next ten years if nothing is done to reduce their risk.
Good record-keeping is an essential part of a successful mini-clinic as trends are all important. Most GP computer systems are not ideal for keeping diabetic records and a separate system may be required. A good call and recall system should ensure that patients do not get "lost" while defaulters are "chased up".
It could be easy to become disheartened by the rigorous targets that have been set for glycaemic control, blood pressure and cholesterol, but quite modest improvement in these parameters can make big improvements in overall risk.

[[NIP01_ppb_2]]

References

  1. Reaven GM. Role of insulin ­resistance in human disease. Diabetes 1988;37:1595-607.
  2. Joint British Recommendations on Prevention of Coronary Heart Disease in Clinical Practice. Heart 1998;80(Suppl 2):S1-29.
  3. Department of Health. National Service Framework for coronary heart disease. London: Department of Health; 2000.
  4. The Diabetes Control and Complications Group. Effect of ­intensive treatment of diabetes on the development and progression of long term complications in insulin ­dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
  5. Testing times. A review of diabetes ­services in England and Wales. London:?Audit Commission; 2000.
  6. United Kingdom Prospective Diabetes Study Group. Intensive blood glucose control compared with conventional treatment and the risk of complication in patients with type 2 diabetes. Lancet 1998;352:837-53, 854-65.

Resources
Primary Care Training Centre (Offers courses for GPs and nurses on the management of diabetes, coronary heart disease prevention, women's health and triage for primary care professionals)
W:www.primarycaretraining.com
Diabetes UK
W:www.diabetes.org.uk
British Dietetic Association
W:www.bda.uk.com
Diabetes National Service Framework
W:www.doh.gov.uk/nsf/diabetes/index.htm

Further reading
Fox C, Pickering A. Diabetes in the real world.
London: Class Publishing; 1995.
Clinical Evidence. (Articles on ­cardiovascular disease and glycaemic control in diabetes, published twice yearly by BMJ Publishing Group.)
December 2000 ISBN 0 7279 1498.