Far from the "mild" disease it has traditionally been thought, diabetes is a chronic, progressive disease process with potentially life threatening complications (NSF, 2001). There are currently more than a million people in the UK diagnosed with diabetes, and the number is steadily rising (NSF, 2001). In fact, it is estimated that there may be as many as 50% of people with type 2 diabetes who are undiagnosed, perhaps suffering only mild symptoms that they live with as "normal" for them (Krentz, 2000). In nursing practice it is vital to understand the condition and to be aware of the health implications for all affected patients. It is a condition that affects all ages and races, and both sexes.

The aim of this essay is to examine the disease process, to discuss the impact of diagnosis on the physical, mental, social and emotional health of a patient, and to evaluate the care of one patient, especially during his changing therapy requirements. Research has shown that good glycaemic control throughout the whole life of a person with type 1 or type 2 diabetes will prevent or delay the onset of complications (DCCT, 1993 & UKPDSG 1998a), but in practice this is recognized as being very hard to achieve. The focus of diabetes care in the UK has changed from being treatment based to aiming at empowering the patient through education, support and regular screening for complications (Jerreat, 1999).

The writer at present works as part of the multi-disciplinary team in an adult diabetes centre within a large, busy general hospital. The team consists of consultant diabetologists, registrars, specialist clinical assistants and senior house officers, diabetes specialist nurses, a nurse trained in screening for complications, clinic nurses, dietitians, podiatrists and retinal screeners and technicians. There are also close links with consultant ophthalmologists, nephrologists and other related specialists as necessary.

When a patient is diagnosed with diabetes they are referred to one of the consultants for ongoing care, and in most cases will have a consultation with one of the diabetes specialist nurses (DSN) first. This is an opportunity to begin to assess the level of knowledge the patient may already possess, so that misconceptions can be corrected at an early stage. The DSN will hopefully begin to build up a rapport with the patient so that if he or she has worries or queries about their health, they will feel able to communicate with the nurse. As this is a condition that will affect the rest of a person's life, a good start to building a working relationship with the diabetes care team is an important step towards empowering the patient to be in control, rather than be controlled by the diabetes (Jerreat, 1999).

The patient chosen for the care study portion of this essay is a man with type 2 diabetes, and is quite representative of a large proportion of the diabetic population seen at the clinic. All names and identities of people and places have been changed to protect the privacy of patients and staff in accordance with UKCC guidelines (UKCC, 1998).


Diabetes Mellitus has been recognized for over 100 years but until the discovery of insulin in 1922, accredited to Frederick Banting and Charles Best, most people were treated with a diet close to starvation levels, and certainly children with type 1 did not usually survive past their second birthday (Scobie, 2002). The reason for the onset of diabetes is still not fully understood in all cases (Scobie, 2002). From all over the developed world there is an immense amount of ongoing research into treatment for people with diabetes, especially in the areas of patient education and empowerment, and health outcomes are improving greatly (Jerreat, 1999). However, there is still some way to go to reduce the incidence of complications to meet even the targets set by the St. Vincent's Declaration in 1989 (Jerreat, 1999).

Diabetes Mellitus is now known as Type 1 or Type 2 (WHO, 1985). (It is not within the scope of this essay to discuss the other types of diabetes). In a healthy body the level of glucose in the blood (and therefore available to the tissues for energy) is largely governed by the production of the hormone insulin. The beta cells in the islets of Langerhans in the pancreas produce the insulin in response to a rise in blood glucose levels. This allows glucose not needed immediately for energy to be stored in the liver and muscle tissues as glycogen. When the body has need of energy, and blood glucose levels are insufficient, the lowered insulin levels stimulate the conversion of the stored glycogen back to glucose (ref).

Type 1 diabetes is an autoimmune condition in which destruction of the beta cells leads to a total lack of insulin produced in the pancreas, and the resulting rise in blood glucose levels cause more urine to be produced by the kidneys in an attempt to rid the body of the excess glucose. It seems likely that an environmental factor such as a virus may be the trigger mechanism for the autoimmune response in a person with a genetic predisposition (Scobie, 2000). A person whose pancreas fails in this way will have severe symptoms, and be extremely unwell. Insulin replacement therapy is absolutely essential for this condition (Scobie, 2002). If undiagnosed or inadequately treated, the rapid onset can lead to ketoacidosis, fitting, coma and even death (Williams & Pickup, 2000). Approximately 15% of people with DM in England have type 1, and the onset is usually in childhood or early adulthood (NSF, 2001).

Type 2 diabetes has two main causes. Either one, or more commonly both, may be present for diabetes to occur. The beta cells in type 2 may gradually become less effective at insulin production, or there may be a degree of resistance to insulin in the tissues. Insulin resistance is more common in those who are overweight, and as the average weight of the UK population is increasing (ref) this is thought to be leading to the increase in development of diabetes.

Type 2 diabetes is more commonly diagnosed in adults over 40, but is becoming more common in a younger age group also (NSF, 2001). This condition is more complex, being of slower onset, with less severe symptoms, and may be undiagnosed for some years before being recognized. There must be a genetic predisposition for the condition to develop, and usually a patient will present following a "trigger", e.g., an illness or trauma, which they may perceive to have "started" the diabetes. However a person receiving a diagnosis of diabetes may be quite devastated if they realize that the condition can have far reaching implications for their future life and expectation of health (Jerreat, 1999).

The definition of Diabetes Mellitus has recently been reviewed and updated to consider the aetiology of the condition, and place less emphasis on the mode of treatment (WHO 1985). Previously, diabetes was defined by the method of treatment the patient was using to control blood sugar levels. Thus it was known as insulin dependent or non-insulin dependent diabetes mellitus (IDDM or NIDDM). In some cases, patients who have had diabetes for some time, at first treated by oral hypoglycaemic agents (OHAs), may need additional insulin therapy to try to improve their increasingly poor control. In the previous definition of diabetes their type of diabetes seems to change, when in reality they are still producing a little insulin from the pancreas, but it is either insufficient for the needs of the body, or the resistance in the peripheral tissues is such so as to render it partially or almost completely ineffective. This can be the case in severely obese people (Williams & Pickup, 2000). The first diagnosis would therefore still be accurate, but it would be noted that they have type 2, insulin treated, diabetes. IT is however possible for the condition to change, especially if there is other aetiology occurring in the body (Scobie, 2000), and the medical team must always be aware of this possibility.
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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 ...

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