Tag Archives: chronic disease management

Symptoms of Diabetes

(Guide only, type 2 diabetes can be asymptomatic for years)

Symptoms Type 1 Diabetes Type 2 Diabetes
Onset Fast (days/weeks) Slow (months/years)
Thirst √ often profound √
Polyuria/nocturia √ √
Bedwetting in children √  -
Lethargy/tiredness √ √
Mood changes/irritability √ √
Weight loss √++ √+/-
Visual disturbances √ √
Thrush infections (genital) - √
Recurrent infections (boils/ulcers) - √
Hunger √ √
Tingling/pain/numbness in extremities - √
Occasionally abdominal pain √ -
Confusion If advanced √ Especially in the elderly
Incontinence - √ Especially in the elderly
Glucosuria √ May be absent especially in the elderly or if there is a high renal threshold
Ketones in urine or blood May be present (ketoacidosis) Likely to be present

Thanks to Practice Nurse 41 8

Type I Diabetes

Type I diabetes occurs when there is a loss of insulin secretion ability due to automimmune destruction of the beta cells in pancreatic tissue. Patients generally present with the symptoms of hyperglycaemia including ketoacidosis.

Type I diabetes is the most common form in young people (affecting aout 0.5% of the population); bringing with it the potential for problems such as retinopathy, neuropathy, nephropathy and vascular disease.

Small amounts of insulin are produced by the pancreas throughout the day to ensure cells have access to glucose, and suppress the release of stored glucose from the liver. During fasting periods, glucagon is released to ensure glucose supplies for brain function.

Carbohydrates are digested in order to provide glucose, which results in the release of insulin titrated to the supply of glucose to use and store glucose in suitable quantities.

Insulin needs to be replaced in type I diabetes patients to ensure 24 hour cover. Boluses may also need to be prescribd to match carbohydrate intake at mealtimes. Often this can be suitably treated with a twice daily insulin if the patient’s daily routine is predictable, for patients whose lifestyle is more varied, titrated insulin may be required perhaps involving a pump or more frequent injections.

Carbohydrate awareness is important for those with type I diabetes because it is carbohydrates that affect blood glucose levels, and therefore patients need to be aware of the carbohydrate values of the foods they consume. This is particularly important for those titrating their insulin.

One of the ways insulin titration is done is through ‘dose adjustment for normal eating’ (DAFNE) which was designed for those with type I diabetes and can contribute to an improved quality of life and satisfaction for patients. Research shows that patients on DAFNE treatment are less likely to be admitted to hospital with ketoacidosis or hypoglycaemia, and also the treatment can make huge cost savings for providers. It consists of a 38 hour training course delivered in a group session based around competency skills. The scheme is successful in promoting understanding of diabetes, awareness of implications regarding diet, and the skills and knowledge required to count carbohydrates and titrate insulin accordingly with the use of DAFNE algorithms.

Translation of PQRST wave

  • P wave shows atrial depolarisation as the atria contract
  • QRS complex shows ventricular depolarisation as the ventricles contract and electrical impulse is conducted from the sinoatrial node, down the bundle of His, into the right and left bundle branches and Purkinje fibres.
  • T wave is the repolarisation of the ventricles as the ventricles relax.

Post-MI Care in Primary Care

Patients with a history of myocardial infarction will need appropriate follow-up in primary care to manage risk factors as far as possible, provide patient education and ensure patients are on correct medication.

Patient education to reduce risks of further MIs is important. In particular, patients should be advised to increase their fruit and vegetable intake to at least 5 portions daily, reducing salt and fat intake, adopting a Mediterranean-style diet including consumption of oily fish. Additional supplements of beta carotene, vitamin C or E are not connected with improving outcomes and reducing cardiac risks. NICE guidelines recommend post-MI patients to consume at least 7g of omega-3 fatty acids per week (2-4 portions of oil fish). For patients unable to achieve this, 1g daily omega-3 ester (Omacor) can be prescribed for up to four years for patients who have had an MI in the previous 3 months. Patients should also be advised to reduce their alcohol consumption to low-moderate levels (less than 21 units per week for men and 14 for women).

Obesity needs to be monitored and managed, as this will not only reduce lipid levels as well as blood pressure but also other conditions such as diabetes.

Smoking cessation help should be offered if appropriate. Nicotine replacement therapy is not advised immediately after an MI, but in the long-term continuing to smoke is a serious risk factor.

All post-MI patients should be offered cardiac rehabilitation with an emphasis on exercise. NICE guidelines recommend moderate exercise for 20-30 minutes (enough to feel lightly breathless) five times per week. Brisk walking is ideal. Sexual activity poses no more risk of a further MI, than in a person who had not had an MI. Although when treating erectile dysfunction it is important to remember that PDE5 (phosphodiesterase 5) inhibitors should be avoided in patients using nicorandil, but can be considered in stable patients six months post-MI.

The optimum lipid target is a total cholesterol of <4mmol/l, LDL cholesterol of <2mmol.

A brief anxiety and depression assessment may be required – referring on to mental health services if necessary.

Air travel can be considered three weeks post-MI, and although the DVLA need not necessarily be notified, it is inadvisable to drive in the four weeks immediately post-MI.

Optimum prescribing for post-MI patients includes:

Daily aspirin (proven to reduce death rate by 25%). This is a lifelong treatment and is a first-line drug. Clopidogrel may be prescribed instead of aspirin if a patient has a well-documented hyper-sensitivity. Clopidogrel may be prescribed alongside aspirin for 12 months in patients with non-ST segment elevation acute coronary syndrome.

ACE inhibitors (particularly in patients with left ventricular dysfunction or heart failure), although current NICE guidelines recommend all patients post-MI should be prescribed ACE inhibitors, after checking renal function. If the patient develops a severe cough or oedema, this would need to be reassessed.

Beta-blockers are responsible for a reduction in mortality of up to 25%. New patients may need to be informed that beta blockers can cause lethargy, but this should resolve after a few weeks.

Statins help reduce lipid levels, and it has been found that after five years’ use they prevent further cardiovascular events in 10% of patients. Statins can be started after liver function and CK has been measured to determine the patient’s baseline, although raised liver enzymes should not necessarily rule out the patient from statin therapy. A statin may be augmented by ezetimibe to reduce LDL and total cholesterol.

A low HDL cholesterol (<1mmol/l) is of particular risk to patient with type II diabetes. Fibrates are effective at raising HDL cholesterol.

Particular attention needs to be paid to the patient’s blood pressure – for post-MI patients the target is <130/80mmHg. To achieve this the beta blocker dose may need to be increased or the patient may also require a diuretic or calcium channel blocker.

Nebuliser Therapy

Most respiratory conditions are treated with an inhaled drug. This enables the drug to effectively target the receptors in the lungs.

Although the nebulising unit of air compressor, mask, chanmber and tubing is commonly referred to as the nebuliser, it’s actually the small contraption attached to the mask which contains the fluid which is the nebuliser. It is this that transforms the liquid drug into fine aerosol. In many cases, inhalers employed with spacers and the proper technique are as effective, or more effective as nebulisers. This may be because of the inefficiency of the method with around 12% of the drug actually reaching the target receptors. This depends on the patients’ breathing rate and depth, the health and age of the patients’ lungs, the volume of the drug being administered and the type of nebuliser chamber. The nebuliser chamber, its components, and air flow rate, determine the size of droplets produced. If the droplet size is too small, the drug will end up in the peripheries of the lungs which decreases the efficacy of the drug. Overfilling the chamber will also affect efficacy as well as prolonging the time taken to administer; this should be 5-10 minutes. Once the nebuliser has finished there is likely to be a small residue of the drug in the chamber.

Nebulisers are not generally indicated for mild-moderate asthma because it has been shown that this can often lead to an overuse of bronchodilators rather than preventers.

Nebulisers are used to administer anticholinergics, corticosteroids, bronchodilators, antifungals and antibiotics as well as recombinant human deoxyribonuclease (used to increase expectoration and reduce viscosity in cystic fibrosis patients). If the nebuliser is used with antibiotics or corticosteroids a mouthpiece should be used to avoid contact with the skin and eyes.

Generally nebulisers are no more efficient than inhalers, and in fact some inhaled drugs are not available in nebuliser form, they can promote over-dependence on bronchodilators in asthmatics and also be habit-forming if the patient enjoys the cooling sensation. It is, however, helpful for patients with reduced manual dexterity or patients receiving palliative care.

Psoriasis

Psoriasis is a common chronic inflammatory skin condition; it is characterised by dry, raised, silvery or red scaly plaques and often follows an unpredictable pattern of exacerbations and remissions. The plaques form as the skin regenerates far quicker than in normal skin (4 days compared with 28 days for normal skin).

The erythema is caused by the capillaries in the dermal layer dilating. This is generally initiated by T cells or antigen presenting cells. The areas most commonly affected are scalp, sacrum, nails, knees and elbows; but psoriasis can affect any area.

The average age of onset of psoriasis is about 33 years, and is equally prevalent in both men and women. Type 1 psoriasis generally begins when the patient is in their 30s, type 2 occurs when patients are in their 40s or 50s. Psoriasis generally declines in those in their 70s.

Psoriasis is found in people with a family history of it, but often it is triggered by factors such as stress or illness. Lifestyle factors such as smoking, poor diet or alcohol consumption can exacerbate psoriasis. Exposure to sunlight can improve it, or can exacerbate it depending on the patient. ACE inhibitors, NSAIDs and some anti-malarials can also make it worse.

There are several types of psoriasis; these include (flexural or inverse psoriasis (affects the flexure of the axillae or knees, generally less scaly than plaque psoriasis), chronic plaque psoriasis (also termed psoriasis vulgaris. This involves red plaques with white scales, normally found on the extensor surfaces of elbows and knees. Sometimes it affects the scalp and occasionally the lumbar region and umbilicus), guttate psoriasis (red scaly papules, many patients with this type of psoriasis will eventually develop chronic plaque psoriasis in time), facial psoriasis (as it implies, but has the most effect on body image), scalp psoriasis (affects the skin within the hairline, often affects the entire scalp), erythrodermic psoriasis (widespread overage, at least 90% of the skin, often connected with systemic illness), palmar-plantar psoriasis (affects the palms or soles), pustular psoriasis (characterised by widespread erythema and sterile pustules).

Psoriasis patients may also be affected by nail disease (this affects around half of patients with psoriasis), and psoriatic arthritis (affects around 30% of psoriasis patients), other co-morbidities may include ankylosing spondylitis and IBD.

Generally GP consultations for psoriasis are referred for specialist treatment, often in nurse-led clinics. As there is no cure for psoriasis, symptom control is the only option. Emollients are the baseline treatment and are used to reduce irritation, moisturise and soften skin scales. Topical therapy may be employed, this is for applications to small areas and includes preparations of corticosteroids, retinoids (vitamin A analogues), and keratolytics. If phototherapy is ineffective or does not provide sufficient relief from symptoms, phototherapy may be employed. This is the application of UVA or UVB light, although this comes with the side affect of increasing the risk of developing squamous cell carcinoma. Systemic therapy may also be employed with the use of drugs such as methotrexate, fumaric acid esters (not currently licensed, but available in some specialist centres), acitretin and ciclosporin. Methotrexate has the added benefits of being suitable for long-term use and effective in the treatment of psoriatic arthritis. Occasionally biologic therapy may be used such as adalimumab, infliximab, ustekinumab and etanercept. These are given either subcutaneously or IV (infliximab); but their use is restricted due to cost.

Although there are therefore many different treatment options for psoriasis, currently there is no cure, so symptom control is the aim.

UK Guidance on Diet could save around 33,000 Lives annually

A study has found if people adhered to the recommended 5 portions of fruit and vegetables each day and reduced their daily intake of salt to 3.5g as well as their saturated fat intake to 3% of their daily energy intake, this could prevent around 33,000 deaths each year. It was calculated that 20,800 coronoary artery disease deaths, 5,876 stroke deaths, amd 6,481 cancer deaths could be prevented each year by following such guidance. Around 12,500 deaths would be in the 75 years and under category.

Scarborough P et al (2010) Modelling the impact of a healthy diet on cardiovascular disease and cancer mortality Journal of Epidemiology and Community Health. Doi:10.1136/jech.2010.114520

Type 2 Diabetes and Daily Step Count in the Middle Aged

Increases in type 2 diabetes have been linked with reduced physical activity. An Australian study has found that an increased daily step count can reduce BMI, and therefore is related to a greater insulin sensitivity amongst middle-aged adults.

Dwyer, T et al (2011) Association of change in daily step count over five years with insulin sensitivity and adiposity: population based cohort study. British Medical Journal 10.1136/bmj.c7249

Diabetes Glucose Testing when Handwashing Facilities are not Available

A study published by Diabetes Care suggests that where handwashing facilities are not available but hands are socially clean and not contaminated with sugar, discarding the first drop of blood and testing glucose from the second drop may be more accurate. Having clean hands is still the gold standard to avoid contamination of the sample, but if handwashing is not possible, the first drop of blood will yield more inaccurate results than discarding the first drop and testing the second. The study also found that applying external pressure on figures could also affect the accuracy of results.

The Difference Between an Ischaemic Foot and a Neuropathic Foot

Ischaemic Neuropathic
No pulse Pulse
Not warm Warm
Ulceration to margins of feet, toes and heels Ulceration to toes and plantar region beneath metatarsal heads
Often diminished sensation Diminished sensation
Sepsis Sepsis
Charcot’s joints
Possible necrosis Local necrosis
Possible gangrene
Pink, painful foot, critical ischaemia oedema

About Lymphoedema and its Management

In 2003 studies were carried out which found that there were at least 100,000 people in the UK who were living with some type of lymphoedema, although this is a conservative estimate, and there could well be 200,00 Britons with lymphoedema (Moffatt 2003).

The lymphatic system maintains homeostasis by transporting interstitial fluid which contains protein, waste products and water back into the blood supply (Keen 2008). If this system fails, or is impaired, protein and fluid can accumulate in the tissues, attracting more water by osmosis which then results in a clearly visible swelling. This is known as lymphoedema (Huit 2000). A sign of lymphoedema is when there is an inability to pinch up a skin fold at the base of the second toe – this is known as Stemmer’s sign (Keen 2008). Oedema ‘pits’ when pressed, and after a few seconds the pit will disappear as the fluid returns (Nigam 2008).

Primary oedema is caused by filiaritic infection caused by mosquito bites (more prevalent in the developing world), congenital conditions such as Milroy’s disease (MacLaren 2001). Idiopathic lymphoedema is thought to occur when there is an underdevelopment of lymph vessels (King 2006).

The most common cause of lymphoedema in the UK is due to cancer treatment such as surgery or radiotherapy which cause damage to lymph nodes or removes them completely (MacLaren 2001). This is known as secondary lymphoedema, it can also be caused by trauma, inflammation (including inflammatory arthritis), or infection such as bacterial cellulitis, tuberculosis or filarial infections (Keen 2008).

Common causes of oedema are pregnancy, immobility, varicose veins and cardiac failure. All of these can contribute to the impairment of the lymph vessels’ ability to transport interstitial fluid back to the blood. Cardiac failure can result in pooling of venous stasis, pooling in the legs, which then puts pressure on the venous system, this can lead to pulmonary oedema (Nigam 2008).

Lymphoedema is not a condition that can be cured, but it can be controlled, and through treatment patients can improve their mobility, decrease the impact inflammatory episodes have on their lives, and enhance their quality of life (Huit 2000). If treatment is not initiated, the condition will gradually become worse. After time, as a result of the accumulation of the excess interstitial fluid, fat and fibrous deposits appear (King 2006). The tissue hardens and the oedema no longer pits; in such cases hyperkeratosis is common (excessive growth of skin to form scaly, horny layers), as is papillomatosis (preponderance or wart growths), and lymphorrhoea (leakage of lymph fluid) (Keen 2008), in some cases if oedema continues, massive oedema known as elephantiasis can develop as the lymph vessels become almost completely blocked, ulcers can also develop which are difficult to heal (Nigam 2008). Because the lymph fluid is protein rich, bacterial and fungal infections are common, which increases the risk of acute exacerbations (Huit 2000). Cellulitis can occur during an acute inflammatory episode and should be treated with broad-spectrum antibiotics (King 2006).

Accurate diagnosis, treatment and patient education of lymphoedema is essential if the best outcomes are to be achieved (Huit 2000). It is also important to diagnose the cause of lymphoedema in order to rule out other causes such as cardiac failure, hypertension, lipoedema, protein deficiency, DVT, or immobility. Defining the cause will ensure the most effective treatment and therefore the best outcome. Clinical presentation, previous medical history, and the results of investigations are all invaluable in determining the cause (King 2006).

Treatment (not cure) is aimed at reducing the oedema and encouraging improved lymph fluid flow (King 2006). There are several principles in the treatment and management of lymphoedema: skincare, compression, exercise, and lymphatic drainage (King 2006). From these four points, it is clear to see how essential patient education is, and how patients themselves can ensure the effectiveness of the treatment prescribed. As with all care planning, the patient should be involved in decision-making and should therefore to be able to give informed consent to proposed treatments.

It is likely that for treatment to be effective, the patient will need to make some lifestyle changes, such as increasing the level of activity and exercise taken, making changes to diet by reducing the intake of salt, and losing weight. Also patients may need to develop new habits such as elevating the affected limb(s) to aid venous return, (oedema responds to gravity and therefore if the affected limb is elevated, this assists in the drainage of the fluid back into the blood supply (Nigam 2008)), taking prescribed medication regularly, and adopt the use of compression garments (Nigam 2008). Because this may mean significant changes to a person’s lifestyle, it is particularly helpful if information can be written down for the patient in order for them to refer back to it in the future (Honner 2009).

Good hygiene and skincare is vital for people living with lymphoedema; the aim is for the skin to be kept supple, healthy and hydrated. Even tiny breaks in the skin can lead to infection (Huit 2000). Soap should be avoided as it removes the natural oils that exist to protect the skin, making it more fragile and prone to breaking. Therefore emollients should be used instead such as aqueous cream. Skin should be patted dry, and care must be taken when moisturising that products are not rubbed into the skin, but rather smoothed over the skin in a downward direction (the direction of the hair) this reduces the risk of folliculitis (Penzer 2003). Skin should be inspected daily for any signs of inflammation discolouration or breaks in the skin, as these could signal an inflammatory episode (King 2006). Patients should also be advised to take care of their affected limbs to reduce the risk of injury to them, wearing footwear at all times, or gloves when gardening or washing up, and using insect repellents and sun block adequately (King 2006).

Compression garments or bandaging can be applied to provide a graduated compression to aid vessels transporting the lymph fluid back into the blood supply, it can also prevent the oedema occurring (Huit 2000). In patients with mild oedema where the shape of the limb has not been distorted and with no contraindication (such as arterial disease, cardiac failure, VTE, or allergies), compression garments can be applied immediately with great effect. Patients need to be assessed and measured for their suitability and sizing for compression garments or bandaging (King 2006). Such garments need to be worn daily if they are to achieve their purpose. Again, this is why patient engagement is essential; without concordance most lymphoedema treatments will fail. For patients with more significant oedema, a period of intensive treatment with compression bandages may be required to reduce the oedema and develop a normal shaped limb in order to fit with compression garments. All of this needs do be done and prescribed by an adequately trained practitioner (King 2006).

Exercise is a good way of decreasing oedema, however, because the oedema itself can be a reason for limited mobility any exercise plans should be tailored for the patient’s needs and abilities (Woods 2004); if compression garments have been prescribed, they will need to be worn during exercise (King 2006). Exercise should be moderate, introducing new exercises gradually and not overdoing it. Low impact exercise such as cycling, swimming and walking are advised (MacLaren 2001).

Lymphatic drainage massage works by promoting the removal of interstitial fluid away from the oedematous areas. It should only be performed by a competent [practitioner as the technique is substantially different from regular massage techniques (Huit 2000). This is a particularly good form of treatment for those patients who are unable to tolerate compression treatments for whatever reason. Again patient involvement is vital – patients can be taught to perform this technique on themselves, which can prove effective (King 2006).

The management of lymphoedema can be difficult, there are many factors to consider, causes, contraindications to treatment, patient concordance, education and lifestyle. The more involved the patient is in their treatment, the more likely it is to be effective. Lymphoedema is often overlooked, but if poorly managed can have a seriously negative impact on a person’s lifestyle, body image, and outlook. Therefore it is imperative that lymphoedema is swiftly diagnosed, treatment determined and initiated to minimise distress and inconvenience to the patient (King 2006).

References

  • Honner, A. (2009) The information needs of patients with therapy-related lymphoedema Cancer Nursing Practice. 8, 7, 21-26
  • Huit, M. (2000) A guide to treating lymphoedema Nursing Standard 96, 38 42
  • Keen D.C. (2008) Non-cancer-related lymphoedema of the lower limb Nursing Standard. 22, 24, 53-6.
  • King, B. (2006) Diagnosis and management of lymphoedema Nursing Times 102, 13, 47
  • Lymphoedema Network (2006) Best Practice for the Management of Lymphoedema International Consensus. London. MEP Ltd
  • MacLaren, J.A. MA, (2001) Lymphoedema
  • Moffatt et al, (2003) Lymphoedema: an underestimated health problem. QJM med, 2003, 96: 731-738
  • Nigam, Y. & Knight, J. (2008) The Lymphatic System Part 4 – Pathophysiology Nursing Times 104, 16, 24-25
  • Penzer, R. (2003) Lymphoedema. Nursing Standard. 17, 35, 45-51.
  • Woods, M. (2004) Causes and treatment of early Lymphoedema Cancer Nursing Practice 3, 5, 25-30

Care of the Post-MI Patient in Primary Care

According to the British Heart Foundation (BHF) in 2006 about 1.3 million people in the UK have had an MI, about 4% of men and 2% of women. Because of their medical history, they will need following up in the primary care setting to help reduce the risk of further events; this is done by a combination of patient education, modification of diet and lifestyle as well as regular checks and medication or further interventions.

In primary care, the major risk factors will therefore be addressed; for example, smoking, obesity, diet, inactive lifestyle, hypertension, dyslipidaemia, poorly-controlled diabetes, as well as ensuring the recommended MI prophylactic medications are prescribed.

Many of these interventions are under QOF with points awarded for specific interventions (such as regular blood pressure checks, blood lipid checks, identification of depression, anxiety or related mental illness, as well as therapies such as ACE inhibitors, beta blockers, aspirin, or angiotensin receptor blockers). It is important for all primary care settings to have robust policies in place for the care of post-MI patients as not all standard therapies are covered by QOF.

Because many of the cardiovascular risk factors are reversible, there needs to be an emphasis on patient education and empowerment. This is the most effective intervention and yet, according to the BHF, less than 40% of post-MI patients have access to this. Primary care nurses are well-placed to provide this.