Specific Nursing Care

 

Diabetes (Type 1 and Type 2)

 

 

 

Introduction

 
People with Type 1 diabetes has a condition where the pancreas fail to produce any insulin due to congenital defects, virus infections or auto immunological suppression.  The sugar (glucose) in the blood cannot be controlled after consuming food containing carbohydrates.  To control the blood sugars in the blood stream, people with Type 1 diabetes has to be put on insulin therapy.  They have to give themselves insulin injections accordingly as prescribed by their diabetologist.
 
In Singapore, about 90% of the people with diabetes are Type 2 diabetes. In type 2 diabetes, the pancreas is still able to produce a certain amount of insulin but is insufficient to lower the blood glucose that are formed in the blood stream after eating carbohydrate.  As the body has not enough insulin to metabolise all the glucose to convert them into energy, glucose starts to accumulate in the blood stream (hyperglycemia) and begins spilling into the urine when the blood glucose level exceeds 10mmol/l (kidney threshold level).

 

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Modification of Dietary Intake

  
Modification of dietary intake helps to control blood glucose levels:

 

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Eat the right amount as advised by your dietician.

 

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Keep fruits and vegetables intake to 2 servings a day.  Examples of 1 serving: 1 fist size apple or orange; 1 wedge of watermelon or papaya; 1 handful of grapes (if small 8 - 10, if big 6 in numbers).

 

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Add fibers to main meals as they will help to slow down the absorption of glucose releasing into the blood stream

 

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Reduce salts, sugar, oil, fats intake.

 

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Drink plenty of fluid.  One should take at least 2 litres of water per day unless contraindicated.

 

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Avoid drinking alcohol as it disturbs blood glucose control.

 

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Look at the contents of each meal.  Ask if the meal is too high in fats, too little fibers, too much of carbohydrates, too oily, too salty, too sweet, or too much gravy added?

 

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Eat at regular times each day.

 

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Check with your dietitian how to do Carb (carbohydrate) counting for each meal.

 

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Have the meal plan review by your dietitian at least once a year.

 

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Exercise

 

Regular exercise is important in diabetic control.  Besides helping in weight loss and lowering blood glucose level, it improves one’s fitness level, strength, well being, blood pressure, and cholesterol level.

 

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Exercises include brisk walking, jogging, cycling, swimming and racquet games.

 

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Choose an exercise that is suitable for the age, physical fitness and the person enjoys doing it on a regular basis.

 

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It is advisable to exercise at least 3 times a week with 20 minutes of resistance exercise (such as *weight lifting at home while watching TV program) and 10 minute of aerobic exercises (brisk walking, cycling, jogging, swimming). 

 

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Exercise must not be excessive but consistent and continuing.

 

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Consult your doctor before starting any new exercise programme. He may need to review the medicine dosage or adjust the meal plan.

 

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Adopt an active lifestyle instead of just sitting down all the time.  For examples do some light housework, go for walks with friends, etc.

 

 

*You can fill-up 2 one-litre water bottles with water or sand and use them as weights.

 

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Medication for Type 1 Diabetes

 

People with Type 1 diabetes need insulin therapy to correct their blood sugar levels.

 

When giving insulin injection, be sure that it is administer in the right dose of the right types at the right time to the right place of the body.

 

There are various types of insulin used for people with Type 1 diabetes. The person should take the insulin according to the doctor’s prescription and according to the pharmacist’s instruction, e.g. to inject half an hour before food, to take just before a meal or at bedtime.

 

As a caregiver, you must know:

 

- how soon the insulin starts to act?

- when the insulin has the greatest effect?

- how long does the action lasts?

- what are the side effects of insulin?

 

 

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Medication for Type 2 Diabetes

 

Medications should be taken according to the doctor’s prescription and pharmacist’s instruction.  For examples, some medicine is to be taken half hour before food while others to be taken immediately after food.

 

Take the medicine regularly at the prescribed times.  Examples to take only in the morning; 2 to 3 times a day or at bedtime only.

 

If the person missed his morning medications, do serve them immediately once you remember.  DO NOT serve the missed dose together with the next dose as this will result in over dosage.

 

As the medicine lowered blood glucose level, it is important to have regular meals and exercise to prevent hypoglycaemia (low blood glucose).

 

Insulin therapy may be needed if the anti-diabetic drugs fail to work in maintaining normal blood glucose levels.

 

As a caregiver, you must know:

 

- how soon the medicine starts to act?

- when the medicine has the greatest effect?

- how long does the action lasts?

- what are the side effects of the medicine?

 

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Monitoring of Blood Glucose

 

It is recommended to have the person's blood glucose check frequently especially when he is sick or unwell.

 

Keep a record book or plot a graph to see the pattern of the blood glucose level.  Knowing the blood glucose state will enable your to take appropriate actions to better the person's diabetes. In this way, you will help to discover how food, exercise and insulin can significantly impact the person's blood glucose level.

 

Bring along this record book each time you visit your doctor.  This is important in helping the doctor to monitor the effectiveness of treatment.

 

The target of a well controlled blood glucose level should read:

 

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4 to 6 mmol/l for fasting blood test.  This is the normal range and diabetic person should keep within this range or as near normal as possible.

 

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Less than 10mmol/l for 2-hour post meal test.  A non-diabetic person should read between 6 to 8 mmol/l.

 

 

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Feet Care 

 

The main goal of taking good care of the feet is to prevent losing them, the digits or even the lower limbs.  Have the person's feet screened at least once a year by a professional (Podiatrist or Foot screening nurse).

 

The following points are important to note:

 

Always maintain foot hygiene.  Remember to change the socks, wash and dry the feet daily.

 

Wear proper foot wear:

 

 
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Footwear with toes covered, especially bedroom slipper, helps to protect the toes from kicking any objects unknowingly.  At home, one may accidentally kick his toes against the leg of the furniture or the door may slam on the unprotected feet.

 

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Wear appropriate foot wear (with socks) for sports or long distance walking.

 

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Avoid Japanese slippers (the thongs may cut the toe-web upon constant rubbing), high heels (the heels may cause stress to the feet), and slippers without straps (give no support to the feet when walking).

 

Prevent injury of the lower limbs.

 

 

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Apply moisturiser to cracked heels or dry lower limbs.

 

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Proper technique of cutting toe nails is important.  Cut them straight across because cutting it curve with round corners may induce ingrown toe nails.

 

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Treat any cuts/wounds immediately.  Wash it with normal saline and dress it daily.  If there is any signs of inflammation and infection, such as redness, pus and fever, consult your doctor immediately.

 

 

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What if the 2-Hour Post Meal Blood Glucose > 10mmol/l?

 

If the 2-hour post meal blood glucose is >10mmol/l, you may need to ask the following questions:

 

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Have the person eaten too much of carbohydrates (rice, noodles, biscuits, fruits/fruit juices)?

 

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Have the person taken food that is high in fats (deep fried; too oily)?

 

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Have the person been sedentary (sitting around at the computer/ TV set/desk or lying around) after his meals?

 

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Are you or the person checking his blood glucose too soon, that is, less than 2 hours after a meal?

 

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Have the person drank enough water that day?  At least 2 litres of water is required per day unless contraindicated.  Water helps to eliminate toxic, waste products and excessive sugar through urination.

 

 

Reflecting on these questions will enable you to make adjustments in your diabetic care plan and that will sure bring a change to the person's blood glucose level.  Document the adjustments you have made and the effects. Discuss them with your doctor or nurse in your next appointment with them. 

 

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Complications

 

Type 1 or 2 diabetes increases the risk for many serious complications.

 

A.  Acute (short term) Diabetes complications:

 

  • Hypoglycemia (low blood glucose)

  • Diabetic Ketoacidosis (DKA)

 

B.  Chronic (long term) Diabetes complications:

 

  • Stroke

  • Eyes- blindness (retinopathy)

  • Heart-disease (cardiovascular disease)

  • Kidney damage (nephropathy)

  • Nerve damage (neuropathy) – in the lower limbs, impotency

  • Amputation

Studies have shown that good control of diabetes can prevent or reduce the risk of these complications.

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Emergency Alert

 
People with diabetes should:

 

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Know the signs and symptoms of low blood glucose and its management.

 

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Always carry some kind of sugar, such as glucose tablets, raisins or sweets.

 

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Wear or carry Diabetes identification information, such as a medical alert bracelet or a Diabetes Medical Alert card that emergency medical staff can find.

 

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Facts about Diabetes

 

Among the different races, the Indians are most prone to the disease, followed by the Malays and then the Chinese.

 

In Singapore, about 90% of the people with diabetes are Type 2 diabetes.

 

About 40% of people are able to control their diabetes by simply controlling their diet and exercise regularly.

 

If your urine test shows both ketones and glucose it may mean that your diabetes is out of control.

 

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