Diabetic Nursing

Diabetes is a condition that requires the use of huge resources and places a very large financial demand on the National Health Service. Current estimates are that around ten percent of the NHS budget is spent on the on going treatment of people with diabetes. The government has been reviewing the standard of care given over the last few years, and produced a National Service Framework to provide an equal level of care across the whole country, and to all individuals (NSF, 2001). The goal of improving the long-term health of people with diabetes has been at the forefront of much research and development for many years, but was highlighted at the World Health Organisation Regional Committee for Europe in 1991. Known worldwide as the St. Vincent Declaration, recommendations were put forward to reduce the impact of diabetes. There have been considerable developments in some areas, and especially in research since then, but the UK is still lagging behind some other developed countries in the areas of blood glucose and blood pressure control (NSF, 2001).

Local district diabetes registers have been set up following the recommendations of the St. Vincent Declaration, and these have made possible the assessment of need and delivery of care in communities (McCarlie et el, 2002). The NSF (2001) aims to join these into a national register, which will allow statistical analysis of care across the UK. Since diabetes is also more common in some ethnic groups (NSF, 2001), the burden of care falls disproportionately on some communities than others. The NSF (2001) aims to provide the evidence needed by such districts to allow appropriate funding to be allocated. It is recognized that poorer areas have less uptake of screening facilities, and subsequently a higher level of complications in the diabetic population (NSF, 2001). Winocour (2001) states that without the necessary funding being made available to set up an integrated and flexible database, the care will continue to be uneven across the UK.

The difficulty with the aims of such initiatives, however, is that improvements in figures on paper do not always reflect the true picture from the patient's perspective. The following case study illustrates that for the patient, diabetes can be a life-sentence of denying himself the food he would like to eat, and feeling guilty when he doesn't do what he knows he should.

CASE STUDY

Tom Stevens, a forty seven year old man has had type 2 diabetes for eight years. He was aware of the condition, as his mother has had diabetes for all Tom's adult life. Aged thirty-nine he started to develop typical symptoms of polyuria, nocturia and excessive thirst, and being aware of the familial tendency of diabetes (Jerreat, 2000), he recognized the probable cause and went to his GP immediately.

A firm diagnosis was given to Tom by his GP, following an oral glucose tolerance test (OGGT). This is an internationally recognized means of determining the diagnosis, and is positive if the fasting blood-glucose level is above 6.9 mmols/litre of venous blood. If below this, the person is given 75 mg glucose in solution to drink, and repeat blood and urine tests taken at one and two hours following (WHO, 1985). A blood-glucose level of 11.1 mmols/l at two hours is also a positive result, although this may indicate impaired glucose tolerance, rather than clearly indicate diabetes, if the fasting blood glucose level was satisfactory (Scobie, 2002). The person interpreting the results must have an idea of the patient's medical history for maximum accuracy. Results are repeated at least once more to ensure the result is accurate, and not affected by another health issue, such as illness or infection.

Although Tom and his family were not surprised at the result, (a fasting blood-glucose of 10.4 mmols/l), there was still a feeling of shock and he and his wife became very apprehensive about his future health. His knowledge of the possible health outcomes suddenly applied to him, and was not just facts on paper. It is vital to be accurate about diagnosing diabetes because there are many long-term implications in the area of employment, insurance, driving, etc., quite apart from the health risks.

The GP referred Tom to the local diabetes care team and he met a diabetes specialist nurse (DSN). At first there was little progress made towards a good working relationship. Tom was reluctant to accept the doctor and nurse's suggestions of ways to change his lifestyle. He felt that his own knowledge was disregarded and that the nurse and his own GP were too eager to start oral medication or insulin therapy, as his initial blood glucose readings were so high.

Because of his family history Tom knew of the possible difficulties that would bring, especially in the area of driving, and that he would be likely to put on more weight (Krentz, 2000). The author can only surmise that perhaps insulin was mentioned at this point as a possibility later on, if diet, exercise and oral medication did not reduce the blood glucose levels within a reasonable time frame. It is the aim of the whole diabetes care team to be honest with the patients, and involve them in each change in treatment by education and support, as opposed to imposing a regime without ensuring full understanding.

There has been a huge increase in access to medical knowledge by patients with the rise in use of the Internet, and it is necessary to recognize this when commencing a new consultation. The patient may have extensive knowledge of the subject, however, not all information gained in this way is accurate, and the practitioner needs to diplomatically assess the level of understanding before trying to educate a newly diagnosed patient (DoH, 2001b). Research recently on diabetic websites has shown that whilst sites of professional diabetic organizations, such as Diabetes UK, have reliable information, they do not provide patients with a "question and answer" type service, and those that do so are not all accurate (Kelly, et. al. 2002). It seems that many people do have questions they want to ask, but the answers do not always come from those qualified in the area of diabetes. Of course, if it is made clear that what is being stated is a personal experience, it may have credibility, but can be of an alarmist nature, and raise unnecessary fears in a new patient.

Tom's job at that time involved a lot of walking around sites, and he was quite fit as he swam fairly regularly and played sports and games with his son. However, he is not a tall man, and his weight had been steadily increasing over the past 10 years, so that his body mass index (BMI) was 35 upon diagnosis. Research shows that a BMI of less than 30, and preferably between 20 and 25 is of benefit to a person with diabetes (Jerreat, 2000). He had spent some time between diagnosis and the DSN consultation looking at diabetes care on the Internet, and was aware that more exercise and losing weight would help to bring down his blood-glucose level (NICE, 2002a).

Tom and the DSN set certain goals together, and both agreed to give this program of diet control and exercise a trial for a few months. Tom commenced a regular program of swimming before work, and brisk walks in the evenings, as well as weekly sessions at a gym. He was taught to use a blood glucose meter and advised when to test. He adapted to this very well at first, and reported an increase in fitness and a reduction in weight. His blood glucose records showed pre-meal readings gradually reduced to about 6-7 mmols/l. This continued for two years and the annual complications checks for retinopathy, nephropathy and neuropathy showed no changes from Tom's initial screening.

However, after this period Tom changed his job and was unable to keep up the increased level of activity, and although his weight had initially reduced, he began to increase in weight and regained his pre-diagnosis weight. This reached a plateau, and remained constant for a further year, but then his glucose levels gradually began to rise. At first he did nothing about this, as his weight began to reduce a little, which he was pleased about, as it had been of concern to him. However, when his daily blood tests were averaging 10-11 mmols/l he contacted the DSN for advice.

The DSN suggested that Tom try OHAs to reduce his glucose levels, and contacted the GP to prescribe metformin tablets. These have the added advantage of reducing insulin resistance in the tissues, and can help to reduce weight (Jerreat, 1999). However, they can have moderate to severe gastro-intestinal side effects, and unfortunately Tom did suffer from abdominal discomfort and diarrohea at first. As metformin is the most suitable for overweight patients, he was persuaded to try a little longer before abandoning its use entirely. Fortunately the side effect symptoms did recede enough for him to remain on metformin.

For a further two years Tom remained stable and showed no signs of diabetic complications at routine annual screening. He then began to have a problem with his knee and required an arthroscopy to investigate the problem. During the wait for the operation, he was unable to walk far, and although he swam from time to time, he was not able to maintain his exercise routine. His home blood glucose monitoring (HBGM) showed average readings of around 10 mmols/l before meals, and there was regular glycosuria.

Although the occasional high reading will have little impact, it is recognized that if not treated, persistently high blood glucose levels will cause damage to bodily tissues at a micro-vascular level (Pickup & Williams, 1998). If raised glucose levels are maintained for even a relatively short period of time, this tissue damage may be irreversible (Riddle, 2001). The particular areas that are likely to become affected are the kidneys (nephropathy), the retina (retinopathy) and the nervous system, especially that which serves the extremities, (neuropathy) as each are served by extremely small blood vessels (Jerreat 1999).

Tom became aware that his vision was not as clear, and went to his optician, who prescribed glasses and suggested he try to bring forward his retinal screening appointment. The subsequent retinal photograph showed small changes to the vessels of the retina, requiring assessment by an ophthalmic consultant. He diagnosed mild background diabetic retinopathy, and although no treatment was required at that stage, Tom was booked for six monthly retinal photographs, instead of the usual year.

With his health seeming to become much worse in a relatively short time frame, Tom was very understandably becoming quite despondent at this point. He was fortunate in that his employer was quite understanding, and allowed time off for appointments, but he didn't enjoy asking, and did miss appointments with the DSN. It is generally thought that many patients see an appointment with a doctor, or at which something is "done" to them or for them (such as a retinal photograph) as of more value than talking with a nurse. However, the meetings with the specialist nurse can be of immense value in that they look at the whole area of lifestyle, and cover diet, exercise, medication as well as symptoms and recordable information (such as blood tests). It is noted that coming to terms with diabetes can be likened to a grieving process (Coles, 1996, cited in Jerreat 1999). In some patients the initial feeling of being in control changes to one of hopelessness, as in Tom's case. An empathetic and honest approach by the DSN can help the patient to feel that the deterioration is not their fault, and help to re-motivate their actions (Jerreat, 1999 & Clark, 2002).

When contact was again restored with the nurse, Tom was found to have been "comfort eating" as he felt that whatever he did would make no difference - "things would get worse, no matter what". Coupled with the lack of exercise, this had caused an increase in glucose levels. As well as gaining weight, his daily pre-meal readings had again risen to an average of 10-12 mmols/l. He was also feeling "down". Depression is more common in people with diabetes than in the non-diabetic population (Krentz, 2000), understandably so when the future health implications are considered, but it is often not acknowledged or treated adequately. With the NSF (2001) emphasis on empowering the patient, the patient's emotional state will need to be understood in order for the patient to be able to set realistic goals.

Tom's diet, exercise and medication were reconsidered, and his tablets were increased, with the addition of a sulphonylurea, and the addition of insulin was discussed for some time in the future if reasonable control could not be gained. He agreed to try to increase his amount of exercise, as it had been very helpful previously in maintaining a satisfactory HbA1c, but was aware that his job took up most of each day, and both he and the DSN were less hopeful that it would be enough to reduce and maintain his blood glucose levels. Another feature of this development in his medication therapy is that sulphonylureas can induce hypoglycaemia, whilst taking metformin this was not a risk as it does not lower blood glucose levels in the same way (Jerreat, 1999). This was discussed with Tom, and he was advised to maintain a regular eating pattern, and take the tablets half an hour before breakfast and his evening meal. He continued to have regular meetings with his DSN.

Tom was given a date for his arthroscopy only a few weeks after he commenced the new medication, and went in for pre-assessment. His glucose levels were still persistently high, and due to this it was decided to delay the surgery, which Tom was understandably very unhappy about. He had a consultation with the DSN and agreed to try insulin therapy in addition to his OHA. Because he had had time to think about it, and the implications with regard to driving and his ongoing health, he had made the decision himself at this time, and did not feel pushed into it by the medical team.

He was given an insulin delivery "pen" and taught to use it, and as he had been quite comfortable with the fingertip blood testing, found it easier than he thought it would be. Patients are often pleasantly surprised that the insulin injection feels relatively painless. This is because the needle is considerably narrower than the lancet used to obtain a drop of capillary blood for testing, and also that it is given into a much less sensitive area. The fingertip is very well supplied with nerve endings for normal touch sensation, and the arm, thigh or abdomen where insulin is injected is less sensitive. He was advised where to inject, and to rotate the sites for maximum absorption of the insulin (Krentz, 2000).

At first Tom was quite worried about causing hypoglycaemia, and was a little too frequent in checking his blood glucose. Too much testing can cause painful fingertips, and as levels vary during the day, can make the patient anxious and feel they are always playing "catch-up", which to some extent they are. However, he soon became more relaxed about the whole process, and as his control returned to a more satisfactory level, he and the DSN were quite happy.

When the next call for his arthroscopy came, his control was much improved, and the surgery was carried out with a small tear in the meniscus being repaired via the arthroscope. During a surgical procedure for a person with diabetes insulin and a glucose intra-venous infusion are usually routine practice (William & Pickup, 2000). The hospital in which Tom was treated has specific protocols for diabetic patients undergoing minor or major surgical procedures. This ensures that all the doctors with responsibility for a patient with diabetes are following the same standard of care. The rationale behind the infusing of insulin and balancing with a glucose intravenous infusion is that any stressful event produces a range of hormonal secretions, leading to a rise in hyperglycaemia. If this is not monitored and treated, it can lead to ketosis (William & Pickup, 2000). In the case of a patient on OHA's, but who is poorly controlled, insulin will also usually be administered (especially for major surgery), and this can often seem like a backwards step, and can be a source of concern or anxiety to them. However, the blood glucose needs to be at optimum levels for a safe surgical procedure with a good outcome for the patient. It is important that the nurse ensures that this is understood by the patient prior to surgery to reduce any unnecessary anxiety.

For Tom, the only problem was that the control he had felt that he was regaining over his condition was temporarily lost. As a man who usually displayed an internal locus of control, he found it hard to relax and give the control of "his" condition to the medical staff (Jerreat, 1999). This can become a problem if the patient feels that he knows more about diabetes than the doctor, and that can actually be the case; at least he knows what living with diabetes is like, which very few doctors can say (DOH, 2001b).

However, the surgery was successful, and once Tom was home from hospital and began to mobilize, he was able to regulate his own insulin and diet again, and feel more in control. As his knee recovered its former strength, he was able to walk, swim and go to the gym as he had several years before. He found that his daily insulin requirements began to reduce and he and the DSN discussed a trial once again without insulin. Having been through a time of feeling that diabetic complications were inevitable, he was not naive enough to think that nothing would ever happen to him. However, he used the experience to build healthier eating and exercise patterns into his life, and involved his wife also. This gave him more support to keep up the effort he had made to change his lifestyle. The insulin was subsequently stopped, and various OHA's used in combination to maintain healthy blood glucose levels.

Tom agreed short and long term goals with his DSN, and diet, tablets and exercise were included. He and his wife now swim several times a week, and Tom cycles to work rather than use the car. As an intelligent and inquiring man, he has a good grasp of the need for good glycaemic control to prevent all diabetic complications (Barnett, 2002). Not all patients understand this, and even for those that do, the changes made are unlikely to continue as a permanent lifestyle change (Clark, 2002). Some patients even find difficulty in taking oral medication on a regular basis (Schectman et al., 2002). There has been much recent work done in motivation for change in type 2 diabetes, and according to Clark (2002), the most successful programme combines dietary restriction, exercise and behavioural modification. This however is only a part of the story, as most patients find that they cannot maintain good glycaemic control by diet + exercise alone (Scobie, 2002), and will eventually require oral medication to supplement these.

When educating a patient with diabetes, care must be taken to ensure that he or she recognizes that diabetes is a progressive condition, and that their requirements will probably change during their life. In most cases this will involve an increase in oral medication, and if insufficient, may well lead to insulin therapy in addition to, or as a replacement to tablets. In practice it is observed that patients often see the need to go "up a level" in their treatment as a failure on their part, but this is not always the case. For example, obesity is a frequent cause of an increase in therapy needs and higher risk of complications (Krentz, 2000), but is seen by many doctors as the fault of the patient. In reality it is a very difficult task to reduce weight with diabetes (Lawrence & Coppack, 2002), and becomes more difficult if insulin therapy is commenced, as insulin is a growth hormone, and therefore will be likely to increase the patient's weight (Riddle, 2001). There is very little pharmacological choice for patients trying to lose weight (Bray, 2001), and failure in this area can lead to disillusionment with self, and thus a negative attitude to all areas of self-motivation or depression.

Alongside glycaemic control, the control of blood lipids and blood pressure are known to be of vital importance to prevent the macrovascular complications of coronary heart disease (Bray, 2001, & NICE 2002b). In many cases, patients suffer no symptoms if they have raised lipids or hypertension, and without regular screening will not be aware that there is a problem. Thus the diabetic screening appointment is an ideal environment not only to identify problems at an early stage, but also to continue the education of each patient on a regular basis. Diabetes UK produces a leaflet explaining diabetes in simple terms, and what investigations a patient attending a clinic can expect to have carried out (Diabetes UK, 2001). With the National Service Framework for Diabetes Delivery Strategy published in January 2003, diabetic care should become of equal quality across the UK, and all patients will have the same access to adequate screening for complications (Diabetes UK, 2003).

CONCLUSION

Research has demonstrated that the most effective way to improve the mortality and morbidity rates of people with diabetes is by patient education and empowerment (Clark, 2002). This enables the patient to make informed choices about lifestyle and treatment, and as demonstrated above by Tom's lifestyle choices, being involved from the first means that there is a partnership of care between patient and medical staff (NSF, 2001). Tom has come to terms with his condition, and feels that he is in control of it rather than the other way around; not all patients respond to education in this way. It can be difficult to accept that empowering a patient means that they are free to make their own health decisions, even if they are considered to be poor choices by the DSN or other medical staff (Jerreat, 1999). It is important not to be critical or condemning in such a case, as the patient may later regret such decisions, and needs to feel that he or she can come for help or advice without censure (Jerreat, 1999).

The medical profession is now coming to accept that targets set, for example, by the UKPDSG (1998a) and the DCCT (1993) studies are somewhat unrealistic in practice, and have the effect of de-motivating patients who fail in their efforts to achieve them (Winocour, 2002). The education of type 2 diabetic patients therefore has to be flexible and able to be adapted to all races, cultures and levels of understanding (Bradshaw et. al., 1999). This has become the role of the practice and specialist nurse, both of whom are in an ideal position to evaluate the effectiveness of particular methods in their local area of practice.

In March 2003 there is to be the publication of an appraisal of patient education models (NICE, 2002a) in which it is expected that individual and group educative methods will be shown to be the most effective (Bradshaw et. al., 1999). Of course, to implement a greatly increased service in this area will require increased funding, which it is hoped will be one benefit to come out of the National Service Framework. Ultimately, the cost to the NHS now to implement the strategies should be recouped later by less use of medical treatment of diabetic complications. The cost to the patient and future benefit is harder to evaluate, but certainly for Tom and his family, encouraging a healthy lifestyle now is making it possible for him to live a life that is as near to "normal" as possible.

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