Patient is unable to self-treat. If conscious, and able to swallow safely, patient should be given one of the following:
Repeat as required and stay with patient until recovered.
If patient is unconscious, he should be put in recovery position, glucagon can be injected if trained to do so. Otherwise dial 999 for ambulance.
(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
To raise blood glucose, take one of the following:
If blood glucose is still below 4mmol/l after 10 mins, or if patient doesn’t feel better, repeat one of the above treatments.
When feeling better, eat some starchy food such as a sandwich or a banana, monitoring blood glucose afterwards.
| HbA1c DCCT (%) | 6.0 | 6.5 | 7.0 | 7.5 | 8.0 | 8.5 | 9.0 | 9.5 |
| HbA1c IFCC (mmol/mol) | 42 | 48 | 53 | 59 | 64 | 69 | 75 | 80 |
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.
Autonomic phase (BM 2.8-4mmol)
Neuroglycopenic stage (BM <2.8mmol)
Washing hands with water increases the accuracy of blood glucose testing, a Japanese study has found. Cleaning with alcohol swabs did not improve accuracy, however.
Hirose, T. (2011) Glucose monitoring after fruit peeling: pseudohyperglycaemia when neglecting handwashing before fingertip blood sampling. Diabetes Care 34, 3, 596-597
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
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.
A study has shown that those who have a high intake of omega-3 fatty acids, particularly from fish are at an increased risk of developing type II diabetes.
Douse L. et al. (2011) Dietary Omega-3 fatty acids and fish consumption and type 2 diabetes. American Journal of Clinical Nutrition 93. 1, 143-150
This is menopause experienced before the age of 45. These patients are more at risk of health conditions associated with the menopause, such as CHS, CVA and osteoporosis if they don’t take HRT.
Early menopause can be caused by a variety of factors such as; viral infections, enzyme deficiencies, chromosome abnormalities such as fragile X syndrome, and Turner’s syndrome. It may also be caused by FSH receptor gene polymorphism and mutation of inhibin B. Other medical factors include hypothyroidism, type I diabetes, Crohn’s disease, SLE, rheumatoid arthritis, Addison’s disease and myasthenia gravis.
There are other factors of a secondary nature which include chemo/radiotherapy, or oophrectomy.
Assessment and diagnoses will require blood tests for FSH, if necessary two weeks apart if there is no calculable cycle, bloods for testosterone, prolactin (to exclude polycystic ovary syndrome) TSH, progesterone (for fertility). Chromosome analysis for fragile X syndrome may be required, also the assessment ought to include a BMI, BP and bone density scan.
Because women with early onset menopause are at greater risk of the associated conditions, it is essential that they are screened initially and also that these checks are made regularly. Patient education regarding reversible risks factors of these conditions is vital.
For early menopause, HRT or a combined contraceptive pill can be prescribed; particularly as contraception still needs to be considered.
Type II diabetes patients with sleep problems are more likely to develop neuropathy and retinopathy related problems. A Birmingham study found that neuropathy and retinopathy were 30-40% more prevalent in type II diabetic patients with obstructive sleep apnoea. (Diabetic Medicine 2011, 28:supplement 1).
Diabetes is a condition with far-reaching consequences. As the population ages, more diabetes-related conditions will occur.
Diabetes is the root cause of the majority of non-traumatic limb amputations, and therefore diabetic foot problems need to be treated as an emergency, according to NICE guidelines.
Diabetic foot problems can include neuropathy, charcot arthropathy (or other deformity), gangrene, ulcers, osteomyelitis, peripheral arterial disease, or infection.
For care of diabetic foot problesm, the multidisciplinary team in an acute setting will comprise: tissue viability nurse, diabetologist, relevant surgeon, diabetes specialist nurse, podiatrist, and possibly a physiotherapist. The aim of the MDT is primarily mobilisation.
Patients with diabetes-related foot problems need to be referred to the responsible MDT within 24 hours of admission. this team will then assess and initiate treatment of the patient’s underlying diabetes, assess and coordinate care for the presenting foot problems, (the assessment is to include a vascular assessment). Infection also needs to be treated immediately; a swab may be taken, but depending on the stage of infection, it is likely that antibiotics are started before results return from the lab. At this point the patient will be assessed with regard to their need for orthotics or other interventions to protect the feet and revent/reduce future problems where possible. The MDT will also begin to consider discharge, so there is a workable plan in place at the right time.
At all stages, the patient must be kept in the loop with discussions and must be a part of the decision-making process. Patient education and empowerment is paramount, as is effective communication with the primary care team taking over care (if necessary).
According to Azmina Govindji (Diabetes Wellness News April 2011) the latest advice to those with diabetes is that a diabetic diet is a low sugar diet, rather than a ‘no sugar’ diet. A lifestyle of exercise and good healthy diet is essential for wellbeing, consuming low levels of salt, sugar and saturated fat, and high in fibre.
A small amount of sugar can be combined with low glycaemic carbohydrates (e.g. pasta and pulses) as low glycaemic foods help to stabilise blood glucose, which prevents the blood glucose increasing too rapidly. All patients with diabetes are entitled to help from a dietitian to enable a healthy yet practical plan.
