Welcome to

CHANNEL VIEW MEDICAL PRACTICE

News Page

Incidence 3-7 % in populations of European origin, 85% of which is NIDDM.

It is a population of high morbidity and mortality and justifies individual management.

Epidemiology IDDM is an autoimmune disorder characterised by Pancreatic Beta cell destruction.

It is characterised by :

• Severe Insulin deficiency.

• Abrupt onset of severe symptoms.

• A tendency to ketosis.

• Dependency on exogenous Insulin to sustain life.

• Young age of onset, 50% < 20 yrs.

• Presence of autoimmune serology markers, Islet cell antibodies, and antibodies to GAD (gamma acid decarboxylase) an enzyme involved in the production of the neuro-endocrine transmitter GABA.

NIDDM is a lifestyle disease that emerges in genetically predisposed individuals, strongly familial, but also strongly associated with; Diet high in saturated fat, Lack of exercise, and Obesity.

It is characterised by:

• Presence of Insulin.

• Usually only moderate symptoms or asymptomatic.

• No tendency to ketosis.

• No dependency on exogenous Insulin. (Though it may be needed if wt reduction and oral Rx fail.)

• Older age of onset, usually >40 yrs.

Diagnosis IDDM is usually easily diagnosed at onset due to the abrupt nature of presentation, with classical symptoms of thirst, polydipsia, polyuria, weight loss and ketosis.

NIDDM, these presenting symptoms are often delayed by 5-10 yrs after the onset of the condition.50% of NIDDM cases are undiagnosed in the population. It often presents with complications of the disease.

Early detection of asymptomatic NIDDMs may be achieved by SCREENING routinely.

> 40s, with central obesity, dyslipidaemia, hypertension, family history of diabetes, and those showing early signs of ischaemic heart disease.

Symptomatic, Random Blood Glucose (RBG) >11 mmol/l

Fasting Blood Glucose (FBG) >7.0 mmol/l

Asymptomatic patients are unlikely to have diabetes if, RBG <7.8 in repeat.

FBG<5.5

Screening at risk population annually. Preferably by FBG, but RBG or urine testing 2 hrs after a meal is acceptable.

Monitoring

Home:

Urine monitoring is simple and crude, glycosuria occurs when the Renal threshold is exceeded, (this varies between 7-12 mmol/l). Persistent absence of glycosuria measured 2 hours after a meal implies that the blood sugar is at least not grossly elevated.

Blood glucose is the most widely used method for monitoring day to day control. It allows patterns of blood glucose levels during the day to be detected .It is therefore useful to help adjust Insulin doses in IDDMs.

HbA1c, Is the best measurement of long-term control. It is now accepted as the "gold standard". It is a measurement of the mean blood glucose over the proceeding 2/12.

Ideal Sub-optimal Poor

IDDM <7.5 % 7-9% >9%

        NIDDM < 6% 6-7.5% >7.5%

Clinical Targets, Please refer to the South Devon Desktop Guide for Diabetes 2000

In respect of BP, Lipids.

Weight < BMI 25.

Sulphonylureas and Insulin increase the risk of hypoglycaemia / wt gain.

Metformin has the advantage of no wt gain and very little increase in hypoglycaemia, and a decreased risk of MI.

Hypotensive therapy; the drop of BP is important not the agent employed. More than 30% of Diabetics will require 3 or more agents to lower their BP to the required Targets.

Morbidity of Diabetes

Diabetes is the most common cause of blindness in UK.

Diabetics are ten times more likely to have an amputation than the normal population.

Diabetes is the most common cause of non-traumatic amputation in the UK.

Diabetes accounts for 16% of new patients entering the renal replacement programme every year.

Diabetics have a 25-30% of developing nephropathy.

Diabetic nephropathy patients are 15 times more likely to die from IHD than the normal population.

 

Take blood for fasting blood glucose and HbA1c. Ask Receptionist to make appt for patient to see Practice Nurse in 1/52.

Discuss general health and well-being, provide encouragement and reinforce need for good control of Diabetes and weight.

Assess knowledge of Diabetes and self management skills ,including personal footcare guide. Reinforce importance of adhering to protocol schedule.

Ask for symptoms of hypoglycaemia (sulphonylureas and insulin) and side effects of treatment.

Evaluate home monitoring data. BP check if previously raised.

Urine testing will be acceptable if unwilling to perform BS at home

For well controlled NIDDMs (HbA1c <7. 5 ) 2-3 samples of home BS every 2-3 weeks.

1 or 2 pre breakfast samples every 1-2 weeks as well as same number 2hrs after main meal.

When Hba1c >7. 5

Monitor more frequently at the above times.

Blood testing Target Action suggested

* Pre meal     4.4 - 6.7 mmol/litre > 8.0 < 4.4
* Post meal     < 10 mmol/litre > 10.00
* Bed time     5.5 - 7.9 mmol/litre < 5.5 or > 9.0

*2 hrs after meal negative if positive

NIDDM         6.0 % if > 7. 5 %
IDDM         <7. 5 % if > 9.0 %

Weigh patient, discuss result and dietary intake.

Record B/P if > Target at annual review ,and continue 3/12 monitoring if > Target (see diabetic care 2000 guide)

Review management of identified risk factors and long term complications.

Enter all findings on Computer Template including follow up date.

Make next appt in 4/12. Discuss any concerns with Doctor.

Doctor Discuss any treatment modifications with Nurse, see patient if needed.

Detection of {silent} complications
Cardiovascular risk factors and events
Re evaluate therapy, Diabetic education and skills.

Discuss general health and well being, ask about any problems { as at 4/12 } particularly re hypoglycaemic symptoms and side effects of treatment.

Provide encouragement and reinforce need for good control, as at 4/12.

Assess knowledge, as at 4/12.

Review home monitoring results

Weigh the patient and discuss result and dietary intake

Check smoking status and excessive alcohol use.

Record B/P. If not < Target continue to monitor 4/12

Arrange bloods to be taken . HbA1c, Fasting BS ,Fasting Cholesterol and

Lipids, U&E, Creatinine

Test urine for Protein, Glucose and Ketones.

If -ve on dipstick for Protein send specimen for microalbuminuria

If +ve send MSU and arrange 24hr urine collection

Visual acuity - with glasses using pinhole if reduced (if recent V/A available from Optician record this instead.) Ensure patient has arranged/had an annual Optician appt, 12/12 following last retinal photo/ screening.

Foot examination as per Foot Protocol

Enter all information on computer Template.

Make next 4/12 appt for review to ensure compliance

Reinforce importance of attendance

Make appt with Dr for 10/7.

1.    Review and discuss the implications from PN. Annual Review
       with particular attention to the Diabetic complications.

        Cardivascular
        Renal
        Opthalmological
        Neurological
        Feet as per Protocol

2.    Assess need for treatment change and lifestyle modification

3.    Assess need for referral

4.    Decide 4/12 review and Annual review appropriate and
       assess need for any variation of Diabetic review protocol.

5.    Document clearly for further management purposes.

Freedom from the symptoms and complications of Hyperglycaemia both long term and short term

Minimal disruption of lifestyle

Minimal psychological distress caused by the disease

Give simple explanation of your role as Practice Nurse

Discuss nature and significance of Diabetes

Discuss fears

Discuss lifestyle in relation to Diabetes e.g. Smoking,Alcohol,Diet,Exercise Weight loss, Erectile dysfunction.

Measure height, weight and discuss target body weight

Perform relevant examination

Blood pressure

Visual acuity

Urine test for Glucose,ketones and Protein. If +ve Protein send MSU and 24hr collection . If -ve to Protein, send specimen for microalbuminuria.

Arrange E.C.G. with Nursing Assistant

Advise patient re importance of appt with optician

FOOT EXAMINATION as per Protocol.

Arrange blood tests with Nursing Assistant, Fasting Blood glucose, HbA1C, U&E, Creatinine, Enzymes, FBC, TFT, LFT and fastingCholesterol/lipids.

Flu/ Pneumovax

Record all findings on computer Template.

Arrange next appt with Practice Nurse for review 4/12. Arrange Doctor appt in 10/7 or other agreed method of supervision.

 

Review Holistic situation and status of NIDDM

With respect to B/P, Blood results, complications and Optician findings

Reinforce Nurse advice

Decide appropriate referrals - Dietician,Opthalmology/Retinal Screening service, Vascular surgeon, combined Podiatry clinic, Cardiologist, Nephrologist.

Discuss and agree Individual management plan and liaise with Practice Nurse on this {Home monitoring and Urine testing}

Arrange any extra appts or review above and beyond the routine appt already arranged by the Practice Nurse.

Symptoms of Ischaemia .

Ask if any problems with feet.
Do cuts or ulcers heal slowly?
How far can you walk?
Why do you stop walking?
Any claudication? Cramp like sensation/tightness or pain in the muscles from buttock to toes?
Rest pain?
Discolouration?

Record these details on computer template

Any burning, tingling, pins and needles?

Now look at Table of Ischaemic and Neuropathic pain

Any history of previous ulceration? If YES, this patient is automatically HIGH RISK.

Can the pt see the soles of the feet? Check whether can or cannot, might be able to do so with a mirror or member of family or friend assisting. These patients are at HIGHER RISK.

INSPECTION

Remove both shoes, socks and all dressings
Assess general hygiene and ability to care for self.
Obvious areas of damage / ulceration
Swelling
Signs of pressure from shoes and socks.
Callus? hard skin? Predictive of future ulcer sites
Deformity. Include anything from a bony prominence such as bunions or claw toes to partial amputation.
Nail care. Problem nails will require Chiropody.

a. Separate and look between each toe.
b. Look on top,underneath the foot and at the heel.
c. FEEL along the top of the foot,the sides and around the ankle.Apply gentle pressure with one finger for 30secs if you suspect oedema.
d. Note changes in temperature using back of hand on lower part of leg moving down towards toes slowly.
e. Is the foot dry?
f. Any breaks in the skin or macerated areas?
g. Palpate both foot pulses on both feet. Dorsalis pedis and Posterior Tibial

Use a 10g Monofilament to detect loss of protective sensation

Neuropathy is deemed present if the 10g fibre cannot be felt at any one of the sites tested.

See diagram of areas to be tested

i.Now determine your patients risk category and issue appropriate leaflet for his/your information.
 

Go through this information with the patient and plan future care involving the other agencies as indicated.

j.If at any time you are unsure of your assessment do please seek a second opinion from either a nursing colleague or a Doctor.

TOP OF PAGE

Send mail to enquires.channelview@nhs.net ONLY for general correspondence.  For repeat prescriptions
                                                                                                      use the links on the Repeat Prescriptions page.
Last modified: September 28, 2005