To keep well and healthy, every person who has diabetes needs good and regular healthcare. The early detection, treatment and continued control of diabetes is very important as this will reduce a person’s chances of developing the serious health problems and complications linked to diabetes. In England and Wales there are new national service frameworks for diabetes (National Service Framework for Diabetes) and in Scotland there is the Scottish Diabetes Framework. Similar decisions for a diabetes framework are being taken in Northern Ireland.
To achieve the best possible diabetes care, the diabetic patient needs to work together with healthcare professionals as equal members of his or her diabetes care team. It is essential that he or she must understand their condition as well as possible so that the diabetic patient can be an effective member of this team. Effective diabetes care is normally achieved by team work, between the diabetic patient and his or her diabetes care team. Looking after their diabetes and changing their lifestyle to fit in with the demands of diabetes is hard work, but it is worth it.
When the patient is in the hospital, he or she must receive a full explanation of their treatment during their stay in hospital and have the opportunity to discuss any particular worries. It is a right of the patient to receive information and if they do not receive an explanation, they should ask for it. The patient should inform the ward team of their usual diet, tablets or insulin treatment.
The patient should have access to the hospital diabetes care team — doctor, nurse, state registered dietitian and chiropodist. The patient should also be allowed to discuss their diabetes so they can manage some aspects of it themselves, such as blood/urine monitoring and injections at the desire of the patient. However, the staff may need to check the patient’s technique and results and they may need to do additional tests of their own.
The objectives of symptom control in diabetes are to avoid episodes of ketoacidosis and to control symptoms resulting from hyperglycemia and glucosuria. Symptom control begins with the measurement of urine glucose as an index of plasma glucose levels.
In starting therapy for diabetic patients, it is best to analyze the urine prior to each meal and at bedtime. The timing of the collections and the method of testing must be understood. Collecting “double-void” urine specimens immediately prior to meals helps avoid testing urine stored in the bladder since the preceding meal.
The patient should be instructed to void about 30 minutes before the meal, drink 2 or 3 glasses of water, and then void again immediately prior to the meal; the latter specimen will then be tested for glucose. The method for testing urine glucose is chosen on the basis of whether the patient normally spills glucose in the urine or not.
Occasional plasma glucose determinations can be timed on the basis of urine test and hypoglycemic symptom reports. The lowest plasma glucose values, usually before meals and at bedtime when the urine is negative for glucose, are generally most useful in regulating the drug and dietary regimens. They help to determine renal glucose threshold and guide interpretation of urine tests.
The cornerstones of ketoacidosis therapy, required in all patients, are insulin and IV fluids. Insulin is given immediately. The choice of insulin regimen should be based on the experience of the therapeutic team; the objective in all approaches is to achieve optimally effective levels of circulating insulin and maintain them until there is evidence of biochemical recovery.
If the patient is treated by insulin, he or she should expect that it may be given via a glucose/insulin drip into a vein if for some reason they are not allowed to eat or drink. If the patient is having anaesthetic, then an anaesthetist will arrange care of the patient’s diabetes during and immediately following the operation. If the patient is treated by tablets, he or she should be prepared that their treatment may need to be changed while they are in hospital, which may involve being transferred from tablets to insulin during their stay.
For continuing treatment, hourly blood glucose determinations and semiquantitation of serum ketones by serum serial dilution will reflect patient improvement. Patients without an appreciable response after four hours should have the insulin dose doubled each hour until a response occurs. After the blood glucose begins to fall, an infusion containing glucose helps to avoid late hypoglycemia.
Potassium loss is estimated from the serum potassium level interpreted in light of the degree of acidosis. As soon as urine flow is known to be adequate, potassium can be added to the infusion. Marked improvement should occur within a few hours.
Plasma potassium levels should be monitored every hour initially. Continual monitoring of potassium levels is extremely important in the management of diabetes because inadequate management of potassium balance is the main cause of death. Bicarbonate is not needed routinely but may be required if acidosis is very severe.
Reevaluation of areas of physiologic abnormalities should direct therapy to any significant remaining imbalances. Treatment should be continued until the patient is able to take fluid freely by mouth. As soon as food is tolerated, a regular diabetic diet and insulin therapy should be resumed.
Diets for diabetic patients should be neither insufficiently detailed nor unnecessarily complex and should be tailored to fit the propensities and lifestyle of the patient. Sociologic, cultural, and economic barriers to patient adherence to a prescribed diet should be considered and avoided.
There is no need to disproportionately restrict the intake of carbohydrates in the diet of most diabetic patients. Flexibility in diet design helps many patients to adhere to an effective program. Lowering of fat consumption may reduce risk factors of coronary heart disease, the most important cause of death and debility in the diabetic.
It is a good idea to take up some form of regular physical activity, such as walking, swimming, dancing or cycling. The patient should consult their doctor or diabetes nurse before taking up any regular exercise, particularly if they are overweight.
The patient should expect to be able to use their own emergency supplies of biscuits, sugary drinks, fruit or glucose tablets to treat hypoglycemia if they are on insulin or sulphonylurea tablets. If the patient does experience a hypoglycemia, he or she should inform the nurse or doctor.
The patient should also expect to be informed and consulted about any changes in their treatment or diet which may be necessary during their stay in hospital — for example, if the patient has Type 2 diabetes, he or she will sometimes be temporarily treated with injections of insulin while in hospital. This will be because their illness or operation has upset their diabetes control.
Whether treatment of asymptomatic hyperglycemia decreases morbidity and mortality is unknown, and there is significant risk of hypoglycemia in elderly patients given oral hypoglycemic agents or insulin therapy. Therefore, it appears best not to use drug treatment for glucose intolerance in elderly patients with normal fasting plasma glucose levels or asymptomatic fasting hyperglycemia.
Blood glucose monitoring is a useful tool for controlling diabetes. It can help to maintain day to day control, detect hypoglycemia, assess control during any illness, and helps to provide information that can be used in the prevention of long term complications.
It is very important that the diabetic patient should follow the treatment that their doctor or diabetes nurse has advised. Diabetic patients will feel much better if they keep their blood glucose levels as near normal as possible. The doctor or diabetes nurse will advise the patient on what are the best blood glucose levels for that specific patient. They can also advise the patient on the many gadgets available that can help them to monitor their blood glucose levels in order to safely say out of diabetes.
A person with diabetes will have to make some changes to his or her way of life. However, by sticking to their respective treatments, monitoring their health condition and following a generally healthy lifestyle, diabetic patients should be able to continue their normal, day-to-day life and take part in the activities that they have always enjoyed.
Attaining good health after being affected with diabetes is the purpose of being in rehabilitation. For program planning, emphasizing the proximal, attainable benefits of just feeling better today and framing those efforts as part of improving health might have more powerful appeal than avoiding more serious complications of diabetes in the future years. Identifying outcomes valued by each person is a key strategy in promoting change in behavior. Focusing on smaller, attainable goals can help develop self-efficacy for diabetic patients.
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