#94394: Diabetes Care and Patient Education

Ketones are acidic waste products of fat metabolism that can cause serious problems when excessive amounts are in the blood. When the body cannot use glucose for energy, it uses fat, a secondary source of energy. When body fat is utilized for energy, acidic waste products called ketones are formed.

When insulin remains unavailable, blood glucose rises, causing osmotic diuresis and loss of electrolytes. Meanwhile, ketones continue to accumulate as the body utilizes fat for its energy source. This leads to acidosis. The process becomes further complicated as acute renal failure may occur to ward off additional fluid losses. The severe dehydration, electrolyte imbalance, and acidosis associated with DKA will inevitably cause coma and death if left untreated.

People with type 2 diabetes are not prone to ketoacidosis because they usually make enough of their own insulin to prevent excessive breakdown of fat for metabolism. In the person with type 1 diabetes, ketoacidosis can develop rapidly when he or she has a cold, the flu, or other type of infection.

Hyperpnea (deep breathing) is usually present as a sign of DKA, reflecting the pulmonary system's response to acidosis. Acetone breath may occur. Signs of dehydration related to DKA include orthostatic hypotension and poor skin turgor. Acute abdominal pain, tenderness, and diminished or absent bowel sounds are commonly associated with DKA and frequently cause the patient to seek emergent treatment. Changes in mental status occur as the ketosis progresses.

Ketonuria develops as excess ketone bodies are excreted in the urine. Several types of urine dipsticks are available for testing urine ketones. The procedure for testing urine ketones is simple and can easily be taught to patients (Table 1). In order to detect the onset of ketosis in the early stages, patients with type 1 diabetes should test urine ketones when [32,33]:

If a patient with type 1 diabetes has blood glucose greater than 300 mg/dL and moderate or greater ketones in the urine, the attending physician should be notified immediately. Immediate emergency treatment is required if the patient with developing DKA is unable to retain oral fluids or if there is an alteration in mental status [33]. Initial treatment of moderate-to-severe DKA normally includes intravenous fluid and electrolyte replacement to correct deficits of sodium, chloride, bicarbonate, potassium, phosphate, magnesium, and nitrogen. The goal of initial therapy is to expand intravascular and extravascular volume and to restore renal perfusion [34].

In cases of mild DKA, when the patient can retain oral fluids and can follow instructions for self-monitoring, medical care over the telephone may prevent hospitalization or an emergency room visit. Efforts should focus on rehydration, restoration of normal blood glucose, and education. Oral rehydration may be accomplished by taking 3–5 ounces of fluid per hour that may be given in small quantities every 20 to 30 minutes. Although taking sugar-free fluids is probably desirable in cases of hyperglycemia, it is more important to prevent or treat the dehydration than the hyperglycemia. Therefore, some programs condone the use of sugar-containing fluids regardless of the blood glucose level. In addition to fluid replacement, patients in mild DKA require supplemental insulin. Education to prevent DKA in the future is also required [33,35].

HHS is a syndrome of severe hyperglycemia and profound dehydration in individuals with type 2 diabetes. Ketosis does not occur in HHS because there is usually enough insulin present to prevent excessive fat metabolism. In the absence of acidosis, the patient with developing HHS does not usually experience the gastrointestinal symptoms (e.g., cramps, abdominal pain, nausea, vomiting) that occur in DKA. Therefore, the patient is less likely to seek medical attention, and extremely high blood glucose levels (usually >800 mg/dL) can result.

HHS generally has a slow and subtle onset, taking place over 24 hours to two weeks. As glucose builds in the blood, it produces a hyperosmolar state. This causes water to be pulled from body cells, including the brain cells, accounting for its signs and symptoms. These include signs of dehydration (e.g., dry skin and mucous membranes, extreme thirst) and signs of decreased mental status, such as lethargy and confusion. Seizures can also result from HHS. There may also be neurologic deficits that mimic stroke, such as unilateral weakness, aphasia, and sensory impairment. In fact, the onset of HHS may be mistaken for a stroke because it most frequently occurs in elderly people and has a slow, progressive onset.

Risk factors for HHS include any condition that results in fluid loss, for example diarrhea or the use of diuretics, especially the thiazides. Decreased fluid intake, infection, illness, and hypertonic tube feeding are other risk factors for HHS. Elderly patients with type 2 diabetes are at high risk for developing HHS, partially due to their diminished thirst sensation, and especially if they live alone or are cognitively impaired.

The primary treatment goal of HHS is fluid replacement and correction of electrolyte deficits. Insulin administration is another important part of treatment for HHS, although glucose levels will not decrease significantly in the dehydrated state. Elderly patients being treated for dehydration should be monitored very carefully for signs and symptoms of fluid overload and congestive heart failure.

Patients with type 2 diabetes and their families should be educated in the prevention and recognition of HHS, especially if the patient is at high risk. Preventive measures include maintenance of adequate hydration and adherence to medications and a meal plan. Proper sick day management and avoidance of medications that can exacerbate hyperglycemia are other effective preventive measures (Table 2).

Prolonged hyperglycemia leads to changes in the structure of the microscopic vessels that supply the retina of the eye, the glomeruli of the kidney, and both the peripheral and autonomic nerves. Although the pathology that leads to the development of these problems is not well understood, it is believed that there are probably multiple underlying etiologies.

Retinopathy

Persons with all types of diabetes are at risk for developing retinopathy. Persons with type 1 diabetes are more likely to develop proliferative retinopathy, the most devastating type of eye disease affecting people with diabetes. In this disorder, the small vessels of the retina become increasingly permeable and eventually rupture. The ruptured vessels are then replaced by new, very fragile blood vessels that rupture and bleed easily, causing leakage into the vitreous. This is further complicated by the abnormal attachment of these new vessels to the retina. Their presence greatly increases the risk for retinal detachment, furthering the progression to blindness.

Early proliferative retinopathy is usually asymptomatic but can be detected during a dilated eye exam. Early identification of proliferative retinopathy can result in treatment that may prevent or delay the onset of blindness. Standards of care for initial retinopathy screening differ for people with type 1 and type 2 diabetes [6]:

Subsequent eye exams for both type 1 and type 2 should be repeated annually. Less frequent exams may be considered following one or more normal exams. More frequent exams are warranted when retinopathy is already present. Women with pre-existing diabetes who are pregnant or who are planning to become pregnant should have a comprehensive eye exam and be counseled on the risk for development or worsening of retinopathy [6]. Pregnant patients who develop retinopathy should be monitored every trimester and for one year postpartum as indicated by the degree of retinopathy [6]. Patient education principles related to the prevention and management of diabetic retinopathy are to inform patients that:

Diabetic Kidney Disease

Diabetic kidney disease most commonly results from damage to the small blood vessels that supply the filtering components of the nephron, known as the glomeruli. Nephropathy occurs in approximately 20% to 40% of people with diabetes [6,39,40]. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, high dietary protein intake, and chronic high blood sugar. Results of the DCCT and the UKDPS have indicated that the risk for diabetic kidney disease can be reduced by 50% when near-normal blood glucose control is achieved and maintained [7,8,38].

Hypertension significantly accelerates the progression of diabetic nephropathy. Therefore, aggressive blood pressure management is indicated for all patients with diabetes. Angiotensin-converting enzyme (ACE) inhibitor drugs are commonly prescribed to diabetic patients for hypertension because they are effective blood pressure-lowering drugs with few side effects. In addition, ACE inhibitors are often prescribed to patients with diabetes even when they are not hypertensive because the drugs in this class have an independently protective effect on the kidneys, which can prevent the onset or progression of diabetic nephropathy. This means that the renal benefits of ACE inhibitors are above and beyond an effect attributable to blood pressure control alone. In addition to renal benefits, ACE inhibitors have been shown to reduce the risk for heart attack, stroke, and cardiovascular-related death in people with diabetes. Examples of ACE inhibitors include enalapril, fosinopril, lisinopril, and captopril. Another similar class of medication, angiotensin receptor blockers (ARBs), may be used in place of ACE inhibitors for delaying the progression of diabetic nephropathy [6]. A commonly used ARB is losartan.

Standards of care for the detection and prevention of diabetic nephropathy include a yearly screening for the presence of albumin in the urine [6]. This microalbuminuria test detects kidney damage in an earlier stage than the standard dipstick test for gross protein in the urine. Screening also includes measuring serum creatinine at least annually. If chronic kidney disease is present, serum creatinine is used to estimate glomerular filtration rate and stage of the disease [6].

Teaching principles related to the prevention and management of diabetic nephropathy include:

Neuropathy

As much as 50% of people with diabetes have some degree of nervous system damage [41]. Severe diabetic nerve disease is a major contributing factor in the development of problems leading to lower limb amputation. Results from the DCCT have provided evidence that maintaining good glycemic control reduces the risk for neuropathy by 60% [7]. This finding indicates that chronic hyperglycemia plays a significant role in the cause or promotion of nerve damage.

The most common type of neuropathy affecting persons with diabetes is sensory neuropathy. Distributed in a "stocking-glove" fashion, sensory neuropathy usually affects the feet and, to a lesser degree, the hands. Damage to the sensory nerves is often accompanied by motor nerve injury as well, leading to muscle atrophy and deformity of the affected extremities.

Signs and symptoms associated with sensory neuropathy are variable. In some cases, patients may experience pain, tingling, burning, or a pins-and-needles sensation in the hands and feet. Other symptoms include numbness, loss of feeling, or loss of temperature sensation in the affected areas. Treatment of sensory neuropathy is focused on attaining optimal control of blood glucose, managing pain, and protecting insensate feet from injury.

In addition to sensory nerve damage, people with diabetes are also at risk for various problems affecting the nervous supply to the internal and regulatory organs. Known as autonomic neuropathies, these conditions may occur in all types of diabetes and can affect any system in the body. These problems include cardiovascular impairment leading to orthostatic hypotension and "silent" myocardial ischemia. Gastrointestinal abnormalities include slowed digestion of food in the stomach (gastroparesis), nocturnal diarrhea, and fecal incontinence. Impaired insulin counter regulation may also occur, resulting in unawareness of hypoglycemia and "brittle" diabetes. Autonomic neuropathy affecting the genitourinary system can cause urinary retention and sexual dysfunction [6].

Patient teaching principles related to neuropathy include informing the patient that good glycemic control can prevent or delay the development of neuropathy and that neuropathic pain can sometimes be lessened when blood glucose control is improved. Medicine may be used for pain relief. There are many teaching principles associated with preventive care of the insensate foot. These will be discussed in detail in a later section of this course.

Macrovascular disease refers to changes in the moderate to large-sized arteries and veins that supply the heart, brain, and peripheral tissue. Ultimately, it is manifested by coronary heart disease (myocardial infarction), cerebral vascular disease (stroke), and peripheral artery disease, leading to vascular foot ulcers. Cardiovascular disease is the foremost cause of diabetes-related deaths and the largest contributor to the economic costs of diabetes, resulting in an estimated $37.3 billion in cardiovascular-related spending per year [6,42]. Moreover, people with diabetes are prone to developing both coronary and cerebral vascular disease at an earlier age than people who do not have diabetes.

A number of factors contribute to the development of cardiovascular disease in the general population as well as in people with diabetes. These include hypertension, obesity, smoking, excess saturated fat and trans fat in the diet, and abnormal blood lipids (dyslipidemia). Diabetes is considered an independent risk factor for cardiovascular disease as well, predisposing the person to atherosclerotic macrovascular complications at an earlier age and with greater severity than the individual who does not have diabetes [6].

Because macrovascular disease associated with diabetes accounts for such high morbidity, mortality, and economic burden, preventive care efforts are of utmost importance. Preventive approaches include healthy diet, regular exercise, aggressive treatment of hypertension, smoking cessation, treatment of dyslipidemia, and maintenance of a healthy body weight. Blood pressure should be checked at every routine medical visit. For patients with diabetes and hypertension, blood pressure targets should be individualized. Those at higher cardiovascular risk (i.e., existing or 10-year ASCVD risk ≥15%), a blood pressure target of less than 130/80 mm Hg may be appropriate, if it can be safely attained. Individuals at lower risk of ASCVD (i.e., <15%) may be treated to a target of <140/90 mm Hg [6].

Patients with diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of ASCVD. A fasting lipid profile should be performed at least once a year and immediately before initiating statin therapy, if statin therapy is indicated [6]. Medication should be initiated for patients whose LDL cholesterol remains greater than 100 mg/dL after lifestyle modification has been instituted. Statins, such as simvastatin, are the preferred first line of therapy for LDL cholesterol lowering and cardioprotection (Table 3). The ADA recommends two statin dosing intensities for use in clinical practice (Table 4) [6]. Meta-analyses, including data from more than 18,000 patients with diabetes from 14 randomized trials of statin therapy, demonstrate a 9% proportional reduction in all-cause mortality and a 13% reduction in vascular mortality for each mmol/L reduction in LDL cholesterol [43].

If targets are not reached on maximum doses of the statin medication, combination therapy using statins and other lipid-lowering drugs may be considered [6]. Principles of patient education related to macrovascular complications include:

Various skin problems occur more frequently in people with diabetes. Hyperglycemia contributes to dry skin and enhances the growth of certain types of skin infections, including boils, cellulitis, and lower extremity ulcers. Fungal infections often affect the areas of the genitalia, skin folds, and between the toes. In addition, infections usually increase blood glucose levels, thereby increasing insulin requirements. Education related to skin care should include the following:

Patients with poorly controlled diabetes have a greater susceptibility for the development of dental problems. The most serious of these, periodontal disease, can cause bone destruction and tooth loss. Signs and symptoms of periodontal disease include puffy, red gums that bleed easily, bad breath, and loose or decayed teeth. Patient teaching related to dental care should include instruction to:

Patient Y's statements reflect a low level of self-efficacy in some important areas of diabetes self-management. For example, she does not believe that she can achieve good glycemic control, and she lacks confidence in her ability to manage the dietary aspects of her own care. The basis for a therapeutic and empowering relationship with Patient Y will begin when these feelings of frustration and helplessness are acknowledged. You can do this by asking open-ended questions that focus on her feelings. For example, you can ask her, "What is the hardest thing for you right now about dealing with your diabetes?"

If you learn that Patient Y's greatest concern revolves around her fear of experiencing serious hypoglycemia, it will then be an important part of your teaching plan to include instruction on hypoglycemia prevention and management. As you probe further, you discover that the fear Patient Y has surrounding hypoglycemia drives her to take excessive amounts of sugar when she perceives that her blood glucose is too low. You find that, in many cases, she takes large amounts of sugar based upon subjective feelings of "being low," without checking her blood sugar first. You also realize that Patient Y's "comfort zone" for low blood glucose, anything less than 100 mg/dL, is actually quite a bit higher than standard values of 60–70 mg/dL for hypoglycemia. You can see that frequently taking large amounts of sugar seems to result in blood glucose values that rebound to very high levels. This is probably a major contributor to her overall pattern of blood glucose fluctuations. Furthermore, you can presume that Patient Y's irregular pattern of eating is another factor in her erratic glucose pattern, probably accounting for the episodes of true hypoglycemia that she has had.

It is important to teach Patient Y that she can safely prevent and manage hypoglycemia in a way that will help her achieve better overall blood glucose control. In order to gain her trust, the patient's fear of hypoglycemia should be validated by acknowledging that it can be a serious side effect of insulin. You want her to know that keeping her safe is your priority as well.

Once trust has been established, you will want to consider Patient Y's readiness to change the behaviors that seem to be causing poor glycemic control. Following is a scenario of how you might accomplish this:

Nurse: "It sounds like having a serious episode of low blood sugar really worries you."

Patient Y: "I've been to the ER with it before, and they told me you can die if the sugar goes too low."

Nurse: "I can understand why you are afraid of having a hypoglycemic reaction. It certainly can lead to serious problems if not treated. Fortunately, most people can either prevent it or treat it in the early stages. I would like to talk to you about some ways of preventing and treating low blood sugar. There are ways that you should be able to prevent low blood sugar without causing so many highs in between."

Patient Y: "That would be good."

Nurse: "It would involve some changes on your part, including what you do when your blood sugar is low. It would involve not taking quite so much sugar so often. Is this something you'd be interested in hearing about?"

Patient Y: "I can think about it. But I don't want to do anything that will let my blood sugar go too low."

By indicating that she will allow you to provide tentative information, Patient Y demonstrates that she is in the contemplation stage of behavioral change. Your role, therefore, is to offer information, provide empathic feedback, and listen reflectively.

Inform the patient of the standard treatment for hypoglycemia, which is to take 15 grams of fast-acting carbohydrate for blood glucose less than 70 mg/dL. In addition, help Patient Y understand the relationship that her irregular pattern of eating may be having on fluctuations in blood glucose. Instruct her that hypoglycemia can usually be avoided by eating a balance of food types every four to five hours throughout the day.

First, acknowledge and validate the patient's fears. Then, in a nonjudgmental way, you can describe to Patient Y how her behavior seems to contribute to the wide fluctuations in blood glucose levels. You could say: "It would probably be better if you checked your blood sugar to see if it is truly low before eating sugar. Then you will not be causing your blood sugar to rise if it is not necessary. In addition, I don't think you need to take as much sugar as you have been for levels less than 100 mg/dL. It is recommended that you only need to treat for low blood sugar if it is less than 70 mg/dL. Even then, you can probably raise your blood sugar with a smaller amount of sugar, like just the orange juice without the added sugar."

Serve as a mirror for her thoughts and beliefs. For example, you may respond to her ambivalence by saying, "Even though you haven't said you want to try these things right now, I get the feeling you might decide to try it at some point. I'll leave you some written information that you can keep on hand."

As you continue to work with Patient Y, you may discover other areas where she needs further diabetes education. You can continue to help her make appropriate decisions about her own care through an empowering approach. Just as you did with the issue of hypoglycemia, you should continue to acknowledge the patient's priorities, assess her levels of self-efficacy, and address her readiness to change behavior. Proper assessment of these areas will allow for the provision of appropriate and effective interventions.

A needs assessment is a systematic way to gather information about experiences, beliefs, and behaviors that the patient has with regard to diabetes self-care. Information gleaned from the needs assessment can then be utilized to develop a teaching plan that meets the individual needs and priorities of the patient. For the nurse, a needs assessment streamlines the teaching process by focusing on the unique needs of the individual. For the patient, the needs assessment is empowering because it addresses his or her perspective of educational need. Thus, an important area to be addressed in a needs assessment is what the patient perceives as the primary learning need. Other areas that should be assessed include current understanding of self-management practices, self-management behaviors that are currently practiced, and relevant psychosocial/cultural factors. Sample questions from a diabetes needs assessment are listed in Table 6.

An effective approach to teaching diabetes self-care in adult settings is to employ various principles of adult learning theory. An important principle of adult learning theory is that adults tend to be self-directed learners who feel a need to learn. Asking the patient what he or she feels addresses this principle of adult learning and is the most important issue during the needs assessment.

Focus Teaching on the Patient's Perceived Problems

Determine what the patient feels he or she needs to know and what the perceived problems are. The adult learner will be more likely to acquire new knowledge and skills when teaching is directed toward specific problems rather than toward a comprehensive set of material.

Find Out What the Patient Already Knows

Adults tend to learn better when teaching incorporates prior knowledge and past experiences. When teaching a problem-solving process, for example, ask the patient how he or she has dealt with a similar situation in the past. Build upon this experience to teach new material.

Keep the Patient Active in the Learning Process

Provide opportunities for interaction, questions, and sharing. Teaching is apt to be more effective when the patient's own life experiences can be incorporated into the lesson.

Allow for Self-Directed Learning

Enhance the learner's sense of autonomy by letting him or her make choices about what is being taught. For example, you can allow the patient to choose the mode of learning or the amount of time spent on a particular topic.

Give the Patient a Reason to Learn

Adult learners generally must perceive the benefits of what is being taught. Address this by giving the patient a brief rationale for the content that you are presenting, focusing on the benefits that can result from learning.

A major benefit of SMBG is that it provides feedback about how well treatment goals are being met. By keeping blood glucose levels as near normal as possible over time, people with diabetes can reduce their risk for acute and chronic complications. SMBG can help prevent hypoglycemia and provide information relevant to adjusting food intake, activity level, and medication [6]. Several studies have shown that SMBG is associated with decreased morbidity and mortality in individuals with type 2 diabetes [52,53,54].

SMBG provides the patient with immediate feedback on how daily choices affect blood glucose levels, giving reliable information for problem solving and decision making [6,51]. For example, SMBG may allow patients to determine the effect that particular foods or groups of foods have on blood glucose. This is especially useful for the patient who may occasionally want to eat a food high in sugar. SMBG can provide feedback indicating whether the sugar has caused a rapid and excessively high rise in blood glucose.

SMBG is also beneficial in that it can be utilized to monitor how psychologic and physical stressors influence glycemic responses [51]. Correlating SMBG results with the presence of stressors can help the patient manage them for better glycemic control.

As stated, individuals with diabetes should be provided with blood glucose monitoring devices as indicated by their circumstances, preferences, and treatment. There is no "one-size-fits-all" approach. Any device used for diabetes management works best when accompanied by education, training, and follow-up [6].

Although the benefits of SMBG are substantial, some patients may be reluctant or unable to perform this task. However, the benefits of SMBG greatly outweigh the disadvantages, and healthcare providers should be prepared to help patients overcome these barriers. Specifically, lower neighborhood socioeconomic status, older age, fewer HbA1c tests, and fewer physician visits were associated with lower rates of SMBG [52]. Black race, high glycemic level, obesity, and a lesser number of comorbidities were also identified as risk factors for less frequent monitoring.

For some with diabetes, costs associated with blood glucose testing can create a significant barrier to testing [51]. When patients have to pay out-of-pocket expenses for medical supplies, financial barriers have been shown to reduce the use of SMBG. It is important, therefore, to weigh the potential benefits of SMBG against its cost, especially when the expenditures for SMBG may come at the expense of other treatment modalities (e.g., medication) [51]. Fortunately, this changed for Medicare-eligible patients in 1998, when the cost of tests strips, lancets, and meters became covered expenses for people with type 1 and type 2 diabetes.

Individuals may not want to check their blood glucose on a regular basis because they perceive it to be an inconvenience that encroaches on their lifestyle. Healthcare providers might be able to help such patients overcome this barrier by providing information about how improved blood glucose control can result in feeling better on a day-to-day basis. Further information may be provided regarding how glycemic control reduces the risk for long-term complications, making patients more able to lead productive lives. The perception that SMBG is inconvenient may also be offset if patients are shown how this procedure can allow for greater flexibility in meal planning. By monitoring the effects of various foods and the timing of meals on blood glucose, patients can have more choices with regard to eating [6,51]. Patients who find regular blood glucose monitoring bothersome may be interested in meters that are smaller, faster, and require fewer steps during testing. Some meters allow for "alternate site" testing, in which the patient can collect a blood sample from the forearm or the thenar aspect of the palm, where fewer nerve endings make the procedure less painful. Additionally, the IDF/SMBG Working Group has suggested possible regimens that may be individualized to address the specific needs of each person with diabetes [51].

The task of SMBG may be too complex for some patients, especially those with sensory or cognitive deficits. Careful selection of the type of meter that the patient will use can overcome these limitations in some cases. For example, meters that do not require fine precision with regard to where the blood drop is placed may be most appropriate for patients with visual or motor deficits. "Talking" blood glucose meters are available for people who are visually impaired. For some patients, it will be necessary to teach family or caregivers how to monitor blood glucose. Patients assume their glucose monitor is accurate because it has been cleared by the FDA. However, there is substantial variation in the accuracy of widely used blood glucose monitoring systems, and few studies have compared meters in a head-to-head manner [6]. Inaccurate blood glucose monitoring systems pose a public health problem because their readings serve as a basis for treatment decisions [55]. The Diabetes Technology Society Blood Glucose Monitoring System Surveillance Program provides information on the performance of devices used for blood glucose monitoring (https://www.diabetestechnology.org/surveillance).

The possibility of user error can be another disadvantage of SMBG. Patients with functional limitations may not be able to get accurate results because they do not have the physical ability to perform the test correctly. Other patients may be careless with their technique due to psychologic indifference, a lack of appreciation for the significance of results, or other behavioral factors. User error may be mitigated by observing the patient's technique at the start of care and following up with periodic checks thereafter. By observing the patient's technique on a regular basis, the message is sent that accurate SMBG results are important and worthy of the time it takes. Similarly, the technique demonstrated by caregivers and family members who assist with monitoring should be observed and evaluated as well [6].

Patients vary in terms of their comfort with technology, and the complexity and rapid change of the diabetes technology landscape can be an additional barrier to patient and provider implementation. Patients with more education regarding device use have better outcomes. The need for additional education should be periodically assessed, particularly if outcomes are not being met [6].

The frequency and timing of SMBG are dictated by the needs and goals of the individual patient [6,51]. Some meters provide advice to the user in real time when monitoring glucose levels, whereas others can be used as part of integrated health platforms [6]. For a patient using multiple daily insulin injections or the insulin pump, testing should be done at least three times per day but may need to be done as often as 6 to 10 times daily [6]. Patients on intensive insulin regimens (i.e., multiple-dose or insulin pump therapy) should consider SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when low blood glucose is suspected, and prior to critical tasks (e.g., driving) [6]. SMBG is also important for patients using oral hypoglycemic medications to monitor and prevent asymptomatic hypoglycemia. The optimal frequency of testing for patients with type 2 diabetes not using insulin is unclear; however, more frequent SMBG (e.g., fasting, before/after meals) may be helpful, as increased frequency has been shown to be inversely correlated with glycemic control [6]. For individuals with non-insulin-treated diabetes, it may be beneficial to perform "focused" SMBG over short periods of time (e.g., five to seven days), both initially and periodically, during the course of their disease, to obtain data to identify glucose patterns that reflect daily glycemic control. Short-term focused SMBG may also be beneficial when individuals [51]:

As stated, it is critical that the patient and healthcare provider be willing and able to use SMBG appropriately and effectively. The patient should possess the knowledge and skills to accurately perform SMBG and interpret the results to adjust food intake, exercise, or pharmacologic therapy to achieve specific goals [6]. The healthcare provider should ensure that the patient is competent to carry out SMBG on an ongoing basis, and the provider should have the knowledge, skills, and willingness to consistently review results to make necessary adjustments to the treatment plan [51]. The frequency of SMBG should be re-evaluated at each routine visit to ensure its effective use [6].

Guidelines for teaching patients how to use a blood glucose meter include:

Additionally, it is helpful to instruct the patient to obtain blood by pricking the side of his or her fingertip. This avoids puncturing the more sensitive areas of greater innervation.

Blood glucose target ranges should be individualized for the patient. While the overwhelming benefits of tight glycemic control have been demonstrated, this is not necessarily the optimal goal for every patient. For example, an elderly patient living alone may have a higher target range in order to reduce the risk of hypoglycemia. In this case, the risk for an episode of undetected and unassisted hypoglycemia outweighs the benefits of warding off long-term complications.

Although the importance of individualized goals should be emphasized, the following target blood glucose levels can generally be recommended for most adult patients with diabetes [56]:

When discussing blood glucose monitoring, it is helpful to consider the "four cornerstones" of diabetes management. Any of these four factors can be responsible for influencing blood glucose control at any given time for a particular patient. They are:

If blood glucose results are lower or higher than desired, the patient should be directed to analyze each of these variables to determine which of them has most likely affected the blood glucose at that particular point in time. Following is a list of questions that patients should ask themselves to determine which of the four cornerstones of management is most likely responsible for current blood glucose results:

Analyzing the results of blood glucose testing should also take into consideration multiple factors related to the working order and cleanliness of the meter. This would also include verifying the patient's blood glucose testing technique and the quality of the test strips being used.

Patient J is a man, 60 years of age, with a history of type 2 diabetes. He was brought to the emergency department after his neighbor found him at home with confusion, lethargy, right-side weakness, and slurred speech. Medical exam and work up in the emergency department revealed that Patient J was severely dehydrated and that his blood glucose was 860 mg/dL. He was diagnosed with HHS, an acute complication of type 2 diabetes. He was admitted to the medical unit on an insulin drip and for intravenous fluid and electrolyte replacement.

After Patient J's blood glucose and electrolytes returned to normal levels, his mental status cleared and he was free of any neurologic manifestations. While in the hospital, he was seen by the diabetes educator. He received instruction on diet, insulin administration, and blood glucose monitoring. His discharge plan was to return home on insulin injections with follow-up and teaching by a home healthcare nurse.

Discussion

Patient J's home healthcare nurse will play a crucial role in helping him prevent another episode of HHS and other serious problems associated with poorly controlled diabetes. One of the most important aspects of his care plan will be to teach and instruct him in SMBG. As an essential component of diabetes care, SMBG will enable Patient J and his healthcare team to monitor blood glucose levels and influential factors. Good glycemic control will not only help this patient avoid acute problems like HHS, it should also help him feel better on a daily basis. Good control can also help the patient avoid the devastating long-term complications of diabetes, such as blindness, renal failure, and cardiovascular disease.

Before developing a teaching plan for Patient J, a needs assessment to determine what he already knows about diabetes self-care should be performed. This should include areas of care such as nutrition, insulin administration, and blood glucose monitoring. The needs assessment in this case indicates that the patient is unable to correctly perform SMBG independently. He is assessed as being ready to learn this procedure because he clearly indicates that he is willing to incorporate this behavior into his daily life.

In order to most effectively teach Patient J this procedure, the principles of adult learning should be incorporated into the teaching strategy. Begin by finding out what he perceives as problems or barriers to successfully performing SMBG. This will empower Patient J by engaging him in the learning process. Furthermore, his interest may be stimulated by providing a brief rationale for what is being taught, including the benefits of SMBG. Continue applying principles of adult learning on an ongoing basis by keeping Patient J active in the learning process and providing him plenty of opportunity to interact and ask questions.

After teaching Patient J how and why to monitor his blood glucose, the nurse will ascertain his ability to perform this procedure by asking for a return demonstration using control solution. Once this is completed, finger sticking and bloodletting techniques may be covered, ensuring that he can perform these properly.

After the procedures have been reviewed, it is important to ensure that Patient J has a thorough understanding of how to interpret his blood glucose results. The patient should have an understanding of how to compare his food intake, activity pattern, medications, and daily stress level to blood glucose results using a diary. When he learns how these factors influence blood glucose, he will be better able to achieve and maintain glycemic control while avoiding problems associated with diabetes.

The national nutrition policy, outlined by the Dietary Guidelines for Americans, serves as a basis for healthy eating by people with or without diabetes [73]. These guidelines focus on a diet composed primarily of nutrient-dense foods, such as whole grains, fresh fruits, and fresh vegetables. The guidelines also recommend moderation when using sugar, salt, and alcohol and advocate the maintenance of appropriate weight. In the past, the Food Pyramid illustrated dietary recommendations for the public based on intake from various food groups.

In 2011, the U.S. Department of Agriculture replaced the traditional Food Pyramid and the interactive version MyPyramid with a program called Choose My Plate (now simply referred to as "MyPlate") [74]. The ADA recommends that patients with diabetes, their diabetes educators, and/or registered dietitians establish a personalized nutrition plan. To assist in establishing a nutrition plan, the ADA developed a program called Create Your Plate as a meal planning template for people with diabetes [75].

Although sugar was previously forbidden to those with diabetes, ADA guidelines for its use have been liberalized in recent years. ADA guidelines now allow individuals with diabetes to occasionally substitute sugar-containing foods for other carbohydrates as part of a balanced meal plan, if adequately covered with insulin or other glucose-lowering medication as needed. The rules for sugar were relaxed because there is little scientific evidence to support the assumption that simple sugars aggravate hyperglycemia to a greater degree than starches.

In 2013, the ADA issued a position statement advocating for the individualization of eating plans for persons with diabetes [76]. In 2019, the ADA issued a consensus report on nutrition therapy [77]. In both documents, the ADA contends that there is no "one-size-fits-all" diet for patients with diabetes and nutritional recommendations should be based on personal and cultural preferences, comorbidities, health literacy, food access, and willingness to make behavioral changes [76,77]. Some of the key recommendations in this consensus report are [77]:

Exchange Lists

Exchange lists were developed by dieticians in the 1950s to help people with diabetes make daily food choices that would maintain a balance of carbohydrate, protein, and fat from day to day. Any food in one group can be exchanged for another food within the same group. An exchange system can be thought of as a "food budget," giving a certain number of food choices to spend at each meal. Examples of exchanges are shown in Table 7.

In the exchange system, each serving of carbohydrate is equal to 15 grams. Patients are given a list of 15-gram serving sizes of common carbohydrate foods and instructed to consume a specified number of servings from each food group per meal or snack. For example, if three servings of starches and grains are recommended per meal, the patient may select any combination of three of the foods listed in the amount specified for that food group [79].

Carbohydrate Counting

The Institute for Clinical Systems Improvement asserts that a qualified healthcare professional (e.g., a clinician, dietitian, nursing staff, pharmacist) may give a patient diagnosed with type 2 diabetes a meal plan that incorporates monitoring carbohydrates.

(https://www.icsi.org/wp-content/uploads/2019/02/Diabetes.pdf Last Accessed: October 28, 2022)

Strength of Recommendation/Level of Evidence: Moderate/Weak

Carbohydrate counting is a method for keeping track of the amount of carbohydrate in each meal or snack. Emphasis is placed on the total amount of carbohydrate in a meal or snack rather than on the source. Limits are set for the maximum amount of carbohydrate that should be consumed for each meal or snack. Foods counted as carbohydrates are starches (including starchy vegetables), sugars, milk, and fruit. Nonstarchy vegetables are so low in carbohydrates that they are generally not included in carbohydrate counting. According to the ADA, evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals [77].

Because carbohydrates affect blood glucose levels more than any other type of food, insulin dosages can be adjusted based on the amount of carbohydrate consumed. This provides an opportunity for fine-tuning blood glucose control, while allowing greater flexibility with meal content and timing for those who are able to handle a higher level of self-management. While the opportunity for tight glycemic control cannot be overstated, the abilities and motivation of the individual should be taken into account before recommending carbohydrate-to-insulin ratios as a self-management tool. In general, counseling people on eating patterns that replace foods high in carbohydrate with foods lower in carbohydrate and higher in fat may improve glycemia, triglycerides, and HDL-C [77].

The Create Your Plate Method

The Create Your Plate Method is a widely used approach to teaching healthy eating choices and is appropriate for people with diabetes [75,80,81,82]. Its premise is that healthy eating and controlling portion sizes can be simplified by using a visual image of a plate showing the proper amounts of foods to be consumed in a meal (Figure 1). The plate method has been shown to help people with diabetes lose weight, plan meals correctly, improve intake of fruits and vegetables, and reduce the incidence of hypoglycemia without sacrificing glycemic control [82].

THE CREATE YOUR PLATE METHOD

Figure 1

Source: [68,75]

The teaching tenets of the Plate Method are [75,84]:

The plate method is very helpful as a first step in learning to control portion sizes and to plan healthy meals. It is also helpful for patients who are overwhelmed by too much information and for those who do not like strict regimens. The plate method is also recommended for people of low-literacy and those who have barriers to weighing and measuring foods [75,83].

Two methods can be used to assess recent food intake and dietary patterns. One method is the 24-hour dietary recall, in which the patient is asked to recall everything that was consumed over the past 24 hours. Another method is to ask the patient to keep a food diary. This is a log kept by the patient for a specified number of days in which he or she keeps an ongoing record of everything that is consumed over that time. While food diaries can provide valuable assessment data to the nurse, they can also benefit the patient by providing feedback on current eating patterns. The following case study will demonstrate how information gathered from a 24-hour dietary recall can be used to formulate a dietary teaching plan.

Patient C is a moderately obese White woman, 67 years of age, who has recently been diagnosed with type 2 diabetes. Her physician has recommended dietary modification and a walking program to manage her diabetes and promote weight loss. No diabetes medications have been prescribed at this time. As the nurse working in her physician's office, you are asked to provide Patient C with education on the dietary management of her diabetes. As part of your needs assessment, you ask the patient to provide a 24-hour dietary recall. The results and analysis of the dietary content are reported in Table 8.

Discussion

After reviewing Patient C's 24-hour dietary recall, you are able to identify areas where you can most appropriately focus teaching about nutrition. You do this by comparing the overall composition of her diet to the general nutritional recommendations. You can see by Patient C's 24-hour dietary recall that she tends to select foods that are high in both fat and sugar. She will need to know that these types of foods add unnecessary calories to her diet and contribute to her obesity. While you can calculate six servings of added fat in her diet (margarine), you also see that her intake contains several sources of "hidden fat," which greatly increase her overall fat intake. Examples of the high-fat foods she consumed are cheese, higher-fat hamburger, french fries, and chocolate-covered cookies. You should inform Patient C that for weight and cardiac-risk reduction, these foods should be consumed less frequently. You can suggest substituting lower-fat versions of these foods. These may include lean hamburger, low-fat or nonfat cheese, and a baked potato instead of fries. She can also reduce her saturated fat intake by choosing nonfat milk and nonfat yogurt. In place of margarine, she could consider using nonfat butter substitute or fat-free sour cream.

Assessment also reveals that Patient C's diet is low in fiber and vegetables and lacking fresh fruits of any kind for the particular day being examined. You can recommend that she begin substituting some of her higher-calorie food choices with fresh fruits or vegetables. This will help her lose weight while increasing her fiber intake. You can teach her about fruit serving sizes so that she does not increase her overall intake of sugar with the addition of fruit to her diet. The benefits of weight control should be emphasized, as some people with type 2 diabetes are able to control their diabetes with weight reduction alone.

Another point revealed by Patient C's dietary report is that most of her caloric intake is concentrated toward the end of the day. She should be advised that her glycemic control could improve if she distributes calorie and carbohydrate intake throughout the day. She can achieve this by eating smaller meals and snacks and spacing them evenly throughout the day. Eating breakfast can have a positive influence on appetite control, food choices, and metabolism, and thus help with weight management. A possible reason for this is that eating breakfast helps the person avoid becoming overly hungry, which can later lead to overeating and poor food choices. It is also believed that eating a healthy breakfast can set the psychologic and behavioral tone for the day, prompting better food choices overall [85].

After providing Patient C with these general guidelines for nutrition, you can begin teaching her about portion control using the plate method. An actual 9-inch dinner plate and food models can be used to help her visualize the amount of foods that she should be eating from each group. The recommended meal plan can be individualized by taking into account the types of foods that the patient is already eating. Then, you can suggest healthier substitutions for those foods so she is not faced with major changes in basic dietary content. To illustrate this concept, each food group will be discussed in turn.

Grains and Starchy Foods

Some of Patient C's starch choices were appropriate, and she can be encouraged to continue these foods in appropriate amounts. These included whole-wheat crackers (encourage lower-fat choices) and the baked potato, assuming appropriate portion size. Both of these starch sources add fiber and other nutrients to the diet. She should be instructed that she could significantly increase her intake of fiber from the potato by consuming its skin. The nurse should help Patient C explore potential substitutions for the less appropriate sources of starch in her diet. For example, a baked or boiled potato, with skin, could be substituted for the french fries, and whole-grain breads should be substituted for white. You can also explore ideas for increasing whole grain intake at breakfast. This can include eating oatmeal, high-fiber sugar-free cold cereals, or whole-grain breads.

Non-Starchy Vegetables

For patients with diabetes, vegetables provide a moderate source of carbohydrate with the benefit of being rich in fiber, vitamins, and minerals. They offer the added benefit of being naturally devoid of fat and very low in calories. Although canned and frozen vegetables may be an acceptable source, fresh produce is desirable.

Like many Americans, Patient C probably does not consume enough fresh vegetables on a daily basis. While one cup of canned green beans partially fulfills her daily serving allowance of vegetables, she could obtain more nutritional value from fresh sources, such as salads and raw produce. These are often higher in fiber and provide more variety of vitamins and minerals. They may also be more satisfying because the serving size for raw vegetables is larger than for cooked. Fresh vegetables also require more chewing and take longer to eat. The ADA recommends at least three to five servings of vegetables per day. This is a minimum requirement, and more is considered better. Non-starchy vegetables do not need to be counted when using the carbohydrate counting method. When following the plate method, half of the plate should be covered with non-starchy vegetables and salad can be added on the side [86].

Fruit

Although fruit is a source of fructose, or fruit sugar, it is not forbidden to individuals with diabetes. There are many health benefits to eating fruit, including its provision of fiber, vitamins, and minerals to the diet. In the case of Patient C, she should be advised to begin reducing the amount of sucrose that she eats and replacing it with three servings of fruit each day. Whole fresh fruit is desired, although unsweetened canned fruit is acceptable. Whole fruits are strongly advised over juice because they offer the benefits of fiber, take longer to ingest, and may be more filling than juice. When instructing the patient about serving sizes of fruit, it should be emphasized that one serving is equal to a small piece of fruit, ½ banana, or 1¼ cup of strawberries.

Milk

Patient C should begin substituting nonfat milk and yogurt for the low-fat types she is currently using. When selecting yogurt, it should be plain or sweetened with a sugar substitute. Sugar-sweetened yogurt typically contains about 30 grams of carbohydrate, which is the same amount that she would get from two servings of milk.

Protein

Because cheese is categorized as a meat/protein, Patient C's 24-hour dietary recall reflects a surplus intake. She should be advised that large quantities of protein in the diet generally add to its fat content, especially if red meats, fried meats, or high-fat cheeses are selected. Although skinless baked chicken represents an appropriate meat choice for Patient C, she should be encouraged to make choices such as these more consistently. Strategies would include reducing portion sizes and consistently selecting poultry and fish over red meat. It should be reinforced that it is desirable to prepare meats by baking, broiling, and boiling. Meats that have been fried or have had fat added should be avoided. Processed meats, such as lunchmeat and hot dogs, should also be avoided due to their high fat and sodium contents. When selecting cheeses, the patient should be advised to choose lower-fat varieties, such as cottage cheese or reduced-fat hard cheeses.

Fat

As discussed, sources of hidden fat should be avoided in the diet. The number of recommended fat servings refers specifically to fat that has been added to food. An example of added fat included in Patient C's diet is the margarine that she used on her bread and potatoes. On a 1,500-calorie diet, four servings of added fat are recommended. Patient C should be instructed in strategies for reducing her overall fat intake, especially from hidden fat sources. She should be advised to read food labels when shopping to guide her in selecting foods lower in fat, especially the saturated and trans fat types. She can also be referred to a number of cookbooks published by the ADA and the American Heart Association that are readily available in bookstores, libraries, and on the Internet. Other suggestions for Patient C may include ideas for seasoning vegetables and potatoes without fat. Examples include using lemon juice, mustard, nonfat salad dressings, hot pepper sauce, garlic, ground pepper, nonfat sour cream, and other herbs and spices instead of fats and oils.

Sugar

Guidelines for the use of sugar by people with diabetes have been discussed. Patient C will need education and support in curtailing her high intake of sugar. She should be advised that although sugar is not absolutely forbidden to her now that she has been diagnosed with diabetes, she would need to learn how to make choices about sugar as part of an overall plan for healthy eating. As part of her meal plan for diabetes, Patient C can occasionally substitute a serving of sugar for a serving of fruit, starch, or milk. An example of an appropriate sugar substitution would be to have a 3-inch cookie in place of an orange. It should be recognized that the nutritional value of the cookie is inferior to that of the orange and therefore should only be an occasional substitution.

According to the American Diabetes Association, metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes

(https://www.acpjournals.org/doi/10.7326/M20-2470 Last Accessed: October 28, 2022)

Level of Evidence: A (Well-designed clinical trials or high-quality meta-analyses)

At this time, the only biguanide available in the United States is metformin. Unless contraindicated, metformin is the optimal first-line drug [6]. Metformin is available in generic form and also in an extended-release formulation (Glucophage XR). Metformin has been combined with several other medications, including glipizide (Metaglip) and glyburide (Glucovance), as fixed-combination formulations [18].

Mechanism of Action

The primary action of metformin is to reduce glucose production from the liver [18]. Because metformin does not cause the body to make more insulin, it rarely causes hypoglycemia when used alone. A secondary action of metformin is that it increases insulin sensitivity in the muscle and liver tissue [18]. This provides for better utilization of existing insulin. An added benefit of metformin is its favorable effect on blood lipids. This may contribute to cardiovascular risk reduction in some patients with type 2 diabetes. Metformin is excreted by the kidneys and can accumulate in patients with renal dysfunction [18]. Therefore, it may not be an appropriate choice for all patients.

Nursing Implications and Patient Teaching Principles

Minor but common side effects of metformin include gastrointestinal disturbances such as diarrhea, nausea, and abdominal cramping. Taking metformin with meals can reduce these side effects. Although metformin is unlikely to cause hypoglycemia when taken alone, low blood glucose may still occur when it is taken with insulin or sulfonylurea agents.

Serious side effects are very rare and usually occur in those with impaired renal or liver function. Lactic acidosis is the most serious side effect and can be life-threatening, although it is extremely rare. Because the liver is responsible for removing lactate from the system, patients with a history of heavy alcohol abuse and/or binge drinking should not use metformin. It should be used with caution in patients with congestive heart failure, as an exacerbation of this condition can predispose the patient to lactic acidosis. Metformin should also be temporarily withheld when patients undergo any procedure using iodinated contrast dye due to its excretion by the kidneys.

These oral hypoglycemic medications have been widely used to treat type 2 diabetes since the 1950s. In the past, it was estimated that approximately 40% of people with type 2 diabetes were treated with this class of oral medication, although this has changed significantly, as newer drugs have been introduced. Compared with sulfonylureas, metformin as first-line therapy has beneficial effects on A1c, weight, and cardiovascular mortality. There are little systematic data available for other oral agents as initial therapy for type 2 diabetes [6].

Mechanism of Action

Sulfonylureas act primarily by increasing insulin production from the pancreas. They can be further classified as first- or second-generation hypoglycemic agents. The first-generation agent previously used in the United States is chlorpropamide; however, chlorpropamide and acetohexamide have been discontinued, and tolbutamide and tolazamide are no longer recommended treatment options for type 2 diabetes [18]. Although no first-generation sulfonylurea agents are currently used in the United States, it is important to have an understanding of all medications within this category in the rare case a patient presents with a history of having taken one of these agents. Second-generation sulfonylureas include glipizide, glyburide, and glimepiride, among others [6]. They have largely supplanted the use of first-generation sulfonylureas because they have the convenience of once or twice a day dosing and the potential for fewer adverse effects.

Nursing Implications and Patient Teaching Principles

The primary adverse effect associated with the sulfonylureas is hypoglycemia. Nurses should instruct patients with regard to the risk for hypoglycemia while using these drugs as well as on preventive and treatment measures. The elderly are particularly susceptible to hypoglycemic reactions, largely due to the age-related decline in renal function that slows the excretion of these drugs. Another common adverse effect of medications in this class is weight gain. Other, less common side effects include skin reactions and gastrointestinal disturbances.

Patients should be instructed to take their pills daily, at the same time each day. The standard dose of glipizide is taken three times per day to obtain optimal effect; extended-release glipizide and other sulfonylurea agents are taken only once per day.

The two agents in this class, also referred to as meglitinide derivatives or glinides, are repaglinide, which is a meglitinide, and nateglinide, which is a D-phenylalanine derivative.

Mechanism of Action

Like the sulfonylureas, the nonsulfonylurea secretagogues lower blood glucose by stimulating insulin release from the pancreas. In contrast to the sulfonylureas, these agents are rapidly absorbed and eliminated, with a half-life of approximately 1 to 1.5 hours [18]. When the secretagogue is taken just before meals, the amount of insulin released from the pancreas increases during and just after a meal, mimicking the normal islet cell response to eating. Because of their rapid elimination, these secretagogues do not cause the beta cells of the pancreas to continuously release insulin for long periods of time. Therefore, patients treated with these medications have less risk of hypoglycemia than those treated with sulfonylureas.

Nursing Implications and Patient Teaching Principles

As with the sulfonylureas, adverse effects associated with repaglinide include hypoglycemia and weight gain. However, hypoglycemic episodes related to the use of nonsulfonylurea secretagogues are less frequent and less serious. Other side effects include upper respiratory infection, headache, and inflammation of the nasal and sinus tissue.

Patients taking this agent should be instructed to take their pills 15 to 30 minutes prior to each meal. The number of doses taken is determined by the number of meals eaten. For example, if a meal is missed, the corresponding dose of medication is skipped. Conversely, a dose is added when an extra meal or large snack is taken.

Often described as insulin sensitizers, examples of thiazolidinediones (TZDs) include pioglitazone and rosiglitazone [6]. The first drug in this group, troglitazone, was removed from the market because it was shown to cause serious liver problems in a small number of people [87].

Mechanism of Action

Medications in this class improve the body's ability to use insulin. Insulin action is enhanced by "opening up" the insulin receptors in the liver and skeletal tissues. When this occurs, insulin resistance is reversed and the body is able to utilize circulating insulin more effectively. A secondary action of the insulin sensitizers is that they decrease the production and release of glucose from the liver. Because these agents are not hypoglycemic agents, they will not generally lower blood glucose to levels below normal. When used in combination with insulin or sulfonylureas, the potential for hypoglycemia exists [18].

Nursing Implications and Patient Teaching Principles

In general, the insulin-sensitizing agents are well tolerated by patients. Occasional minor side effects may include headache, dizziness, and edema. A much more serious, but still uncommon, adverse effect of these medications is the elevation of liver enzymes leading to severe hepatocellular injury. Although hepatic injury may be reversible, cases resulting in liver transplantation and/or death have occurred in patients who used troglitazone, a thiazolidinedione medication that has been taken off the market. Pioglitazone and rosiglitazone are associated with a higher level of safety in this regard. Chances of drug-related liver complications can be reduced with proper monitoring. TZDs should not be used in those patients with alanine transaminase values of more than 2.5 times the upper limit [88]. Liver function tests are periodically monitored throughout therapy and should be obtained for all patients at the first symptoms suggestive of liver dysfunction, such as nausea, vomiting, abdominal pain, anorexia, or dark urine [18,87].

In 2006, results from A Diabetes Outcome and Progression Trial (ADOPT), a large, randomized, double-blind, parallel group study, indicated that women taking rosiglitazone had a higher risk for fractures (9.30%) compared to those taking either metformin (5.08%) or glyburide (3.47%). Women taking rosiglitazone were reported to have more fractures of the humerus, hand, and foot. The researchers noted that this increase was not evident in spine or hip fractures or in male patients [89].

Rosiglitazone has been associated with increased risk for angina, myocardial infarction, fluid retention, and worsening of heart failure. The risk for heart attack appears to be higher for those who took rosiglitazone with insulin or nitrates [87]. Therefore, most people who take insulin or nitrates should not take this medication. Furthermore, rosiglitazone is contraindicated in people with heart failure [18,90,91]. In 2007, the FDA concluded that the boxed warning on both rosiglitazone and pioglitazone should be strengthened [92]. In addition to choosing alternative medications for patients with heart failure, patients who use a TZD should be closely monitored for signs and symptoms of heart failure.

Acarbose and miglitol are the medications in this class, which are often described as "starch blockers."

Mechanism of Action

Alpha-glucosidase inhibitors (AGIs) work by slowing the digestion of carbohydrate in the small intestine [18]. This results in decreased postprandial blood glucose levels due to delayed absorption of sugars and starches into the bloodstream.

Nursing Implications and Patient Teaching Principles

Gastrointestinal disturbances are commonly related to the use of starch blockers. These include flatulence, diarrhea, and abdominal pain [87]. In many cases, these side effects are dose-related, are self-limiting with continued use, and may be avoided by starting with low dosages and gradually increasing as tolerated.

Patients should be instructed that pills be taken with the first bite of each main meal. While these drugs alone do not cause hypoglycemia, special instructions should be given to patients who use them in combination with sulfonylureas or insulin. In these cases, patients may encounter a delayed response when trying to treat hypoglycemia caused by other drugs. Because the absorption rate of sucrose is drastically reduced with the administration of AGIs, prolonged hypoglycemia can result when conventional sucrose-containing treatments are administered. In cases when medications causing hypoglycemia are used in combination with an AGI, patients should be given specific instructions on how to treat hypoglycemia. Effective treatment consists of taking three to four glucose tablets, one tube of glucose gel, or 10 to 12 ounces of skim milk.

Recently, there has been a flurry of activity in the development and use of incretin-based therapies for the treatment of type 2 diabetes. As discussed, the two incretin hormones are GLP-1 and GIP. The first FDA-approved incretin mimetic was exenatide, sold under the trade name Byetta or Bydureon (extended-release). Exenatide is available in prefilled injection pens and as a kit containing 2 mg of the drug and a diluent [93,94]. Exenatide injection has been approved for use as monotherapy in the treatment of type 2 diabetes, although it is commonly used in combination therapy.

Since the approval of exenatide, additional GLP-1 receptor agonists have been approved by the FDA for the treatment of diabetes, including albiglutide, dulaglutide, and liraglutide [18]. Liraglutide is a daily injection, while albiglutide and dulaglutide are administered weekly [18,95,96]. As with exenatide, these drugs are approved for monotherapy or as an addition to an existing regimen [18]. However, albiglutide, dulaglutide, and liraglutide are considered second-line therapies. Another GLP-1 receptor agonist, lixisenatide, received FDA approval in July 2016 [18]. In 2019, the FDA approved semaglutide (Rybelsus), the first oral GLP-1 agent for type 2 diabetes [97]. It is not recommended as first-line therapy and is contraindicated in patients with type 1 diabetes or diabetic ketoacidosis. [97]. Oral semaglutide is expected to be available in the fourth quarter of 2019 [18].

GLP-1 receptor agonists, with or without metformin based on glycemic needs, are an appropriate initial therapy for individuals with type 2 diabetes who are either with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease. Among these patients, GLP-1 receptor agonists have demonstrated cardiovascular disease benefit. A GLP-1 receptor agonist is preferred to insulin, when possible, in patients with type 2 diabetes. If insulin is used, combination therapy with a GLP-1 receptor agonist is recommended for greater efficacy and durability of treatment effect [6].

Mechanism of Action

These medications mimic the action of the incretin hormones GLP-1 and GIP, leading to an increase in insulin secretion from the pancreas. An additional beneficial effect is delayed gastric emptying, which increases satiety and promotes weight loss.

Nursing Implications and Patient Teaching Principles

The recommended initial dosage for the exenatide pen preparation is 5 mcg twice daily within one hour prior to a meal [18]. The recommended dosage for the 2-mg kit is once every seven days (weekly); it can be administered at any time of day, with or without meals [18]. Exenatide is not labeled for use with insulin and should not be used in patients with a history or high risk of pancreatitis. If liraglutide is prescribed, the initial dose is 0.6 mg subcutaneously once daily for one week, after which it is increased to 1.2 mg once daily [18]. The dose may be increased to 1.8 mg once daily if optimal glycemic response not achieved with 1.2 mg per day [18].

The recommended dosage for semaglutide is 3 mg once daily for 30 days. This dosage is intended for treatment initiation, not for effective glycemic control. After 30 days on the 3-mg dose, increase to 7 mg once daily. Dose may be increased to 14 mg once daily if additional glycemic control is needed after 30 days on the 7-mg dose. Semaglutide should be taken at least 30 minutes before the first food, beverage, or other oral medications of the day and with no more than 4 ounces of plain water [18]. If a dose is missed, the missed dose should be skipped, and the next dose taken the following day [18,98].

Albiglutide is administered at a dose of 30 mg once weekly, though the dose may be titrated to 50 mg once weekly to effect [18]. The initial dose of dulaglutide is 0.75–1.5 mg once weekly. These weekly medications should be administered on the same day each week.

In 2013, the FDA began investigating unpublished new findings by a group of researchers that suggest an increased risk of pancreatitis and pancreatic duct metaplasia in patients with type 2 diabetes treated with incretin mimetics, including exenatide and liraglutide, among others [99]. The most common side effects are nausea, vomiting, and diarrhea. Hypoglycemia can occur if used in conjunction with a sulfonylurea [100]. The medications also contain black-box warnings due to an increased risk for thyroid C-cell tumors [18]. As the incretin mimetics are administered subcutaneously (with the exception of semaglutide oral tablets), patient education regarding proper injection technique, use of the injection pens, and disposal of used pens may be necessary.

Also known as dipeptidyl peptidase-4 (DPP-4) inhibitors or incretin enhancers, medications in this group include sitagliptin, saxagliptin, linagliptin, and alogliptin [6].

Mechanism of Action

DPP-4 is an enzyme that rapidly inactivates the incretin hormones. By inhibiting DPP-4, gliptins prolong active incretin levels, allowing for increased insulin action following the post-meal rise in blood glucose. Unlike incretin mimetics, gliptins do not slow gastric emptying or produce satiety and weight loss [101].

Nursing Implications and Patient Teaching Principles

The gliptins are oral agents taken once a day, with or without food. They are unlikely to cause hypoglycemia because they do not work well when blood glucose is low. Combination therapy with insulin has not been studied, but gliptins may be used with other oral antidiabetic agents. The most common side effects are upper respiratory infection, urinary tract infection, and headache [102,103,104].

Pramlintide acetate is an analog of the human hormone, amylin. It is an injection to be used with mealtime insulin in people with either type 1 or type 2 diabetes.

Mechanism of Action

Like insulin, amylin is a hormone produced from the beta cells of the pancreas and works with insulin to regulate glucose control. Beta cell destruction can result in deficiencies of both of these hormones. As a synthetic version of amylin, pramlintide acetate functions similarly to the native hormone, working in partnership with insulin to control blood glucose. Amylin also slows gastric emptying, decreasing appetite and promoting weight loss. Additionally, amylin suppresses glucagon secretion, leading to decreased post-prandial concentration in the blood [18].

Nursing Implications and Patient Teaching Principles

Pramlintide acetate (Symlin) is to be injected before meals. When used with insulin, pramlintide acetate has been associated with an increased risk for severe insulin-induced hypoglycemia, especially in patients with type 1 diabetes. This usually occurs within three hours of injection [18,105]. Therefore, appropriate patient selection, careful patient education, and insulin dose adjustments are essential. Patients who have hypoglycemic unawareness, poor compliance with blood glucose monitoring, or a history of severe hypoglycemia should not be considered for use of this drug. Patients who use pramlintide acetate should be instructed to monitor pre- and post-meal blood glucose frequently and to reduce their pre-meal short acting insulin by 50% when starting the medication [18,105]. Other common side effects of pramlintide acetate are nausea, vomiting, decreased appetite, and swelling or itching at the injection site.

Canagliflozin, the first in the new class of diabetes medications referred to as sodium-glucose co-transporter 2 (SGLT2) inhibitors, was approved by the FDA in 2013 [18,106]. Two additional agents, dapagliflozin, and empagliflozin were approved in 2014 [18,107,108]. Ertugliflozin was approved in 2017, and bexagliflozin was approved in 2023 [18,109]. These oral medications are taken each morning.

Mechanism of Action

These agents act by inhibiting SGLT2 in the proximal renal tubules, which reduces reabsorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose. SGLT2 is the main site of filtered glucose reabsorption, and reduction of filtered glucose reabsorption and lowering the renal threshold result in increased urinary excretion of glucose and improved plasma glucose concentrations [18].

Nursing Implications and Patient Teaching Principles

The recommended initial dose of canagliflozin is 100 mg once daily prior to the first meal of the day [18,106]. The dose may be increased up to 300 mg per day, unless the patient has impaired renal function [18]. Dapagliflozin is dosed at 5 mg/day but may be increased to a maximum of 10 mg/day [18,107]. The initial dose of empagliflozin is 10 mg/day, but this may be increased up to 25 mg/day for optimal glycemic control [18,108]. Ertugliflozin is initially dosed at 5 mg once daily but may be increased to 15 mg once daily after 4 to 12 weeks [18]. The daily dose of bexagliflozin is 20 mg [18]. All five agents are approved for use with diet and exercise to improve the control of type 2 diabetes in adult patients. They have been studied for use as monotherapy and in combination with other antidiabetics, including metformin, sulfonylureas, pioglitazone, and insulin [106]. The most common side effects associated with SGLT2 inhibitors are vulvovaginal candidiasis and urinary tract infection [18,106]. In 2018, the FDA issued a warning about rare but serious necrotizing fasciitis of the perineum associated with SGLT2 inhibitor therapy [110].

First approved by the FDA in 2009, only one medication, bromocriptine, in the class of dopamine agonists is approved for the treatment of type 2 diabetes.

Mechanism of Action

Bromocriptine mesylate is a novel formulation of bromocriptine that targets neuroendocrine patterns associated with insulin resistance. As a dopamine D2 receptor agonist, this medication activates dopamine receptors, affecting the circadian clock and its influence on glucose metabolism, insulin resistance, and perhaps cardiovascular pathology [111].

Nursing Implications and Patient Teaching Principles

Bromocriptine mesylate is started at a dose of 0.8 mg orally once daily and increased at weekly intervals in 0.8-mg increments, as tolerated. The usual effective dosage is 1.6–4.8 mg once daily (maximum: 4.8 mg/day). Bromocriptine is quick acting and should be taken within two hours of waking. It should also be taken with food to minimize gastrointestinal effects [18].

Possible adverse effects include nausea, fatigue, rhinitis, headache, and dizziness. These are most likely to occur during initial titration and lasted a median of 14 days in clinical trials [6]. Bromocriptine does not cause hypoglycemia and is not recommended for patients with psychosis or syncopal migraines [6].

With the introduction of new antidiabetic medications, several possible combinations of medications may now be used to treat type 2 diabetes. Combination therapy may include the concurrent use of two or more oral agents, the use of insulin with one or more oral agents, or the use of insulin with pramlintide acetate. The chief benefit of combination therapy is improved glycemic control due to the additive effect of multiple agents acting via different mechanisms. Traditional recommendations have been to use stepwise addition of medications to metformin to maintain A1c at target. The advantage of this is to provide a clear assessment of the positive and negative effects of new drugs and to reduce potential side effects and expense. However, there are data to support initial combination therapy for more rapid attainment of glycemic goals and later combination therapy for longer durability of glycemic effect [6].

Not every possible combination has been adequately studied at this time. Some frequently used and/or well-studied combinations are:

Usual causes of hypoglycemia include an excessive dosage of insulin, insufficient or delayed food intake to match insulin dosage, and/or too much physical activity in proportion to the amount of insulin taken. Symptoms of hypoglycemia may include any or all of the following [112]:

Treatment of hypoglycemia consists of immediately ingesting 15–20 grams of fast-acting carbohydrate. Table 9 provides a list of foods that contain this amount of carbohydrate, along with patient instructions for treating and preventing hypoglycemia. Foods with high fat content, such as candy bars, cookies, and ice cream, are not recommended for the treatment of hypoglycemia because the fat will delay absorption of the food and slow down the response to treatment.

An intramuscular injection of glucagon may be required to treat intractable or severe hypoglycemia in situations when the individual requires assistance. The action of glucagon is to raise blood glucose levels by causing the release of stored glucose from the liver. Blood glucose response usually occurs 5 to 20 minutes after injection. Glucagon is available as an emergency kit that contains the glucagon powder in a vial, along with a diluent-filled syringe and needle. This setup allows for rapid reconstitution of the powder and administration of the dissolved medication. One or more doses may be required to elicit a sufficient response from the patient. When consciousness is regained following administration of glucagon, the individual should be given glucose-containing liquids to restore glycogen stores in the liver and to prevent secondary hypoglycemia. Because nausea and vomiting are the most common side effects of glucagon, the patient should be protected from aspiration if convulsions occur and as consciousness resumes.

Insulin concentrations available in the United States include U100 and U500. However, U100 is used by virtually all patients. U500 insulin is a very concentrated form of insulin that is occasionally used in cases of extreme insulin resistance.

Human insulin and its analogs are the only species of insulin available in the United States today, as the manufacture of beef and pork insulins has been discontinued in this country. Human insulins are manufactured by using recombinant-DNA technology and are preferred over animal-derived insulins as they are less likely to produce antigenic reactions.

Insulin type usually refers to the action time of a particular product. This includes peak effect and duration of action. The currently available types of insulin are rapid-acting, short-acting, intermediate-acting, and long-acting.

Rapid-Acting

Examples of rapid-acting insulins are lispro and aspart. Their distinguishing characteristics are rapid onset, peak, and duration times. Aspart begins working about 5 to 15 minutes after injection, with peak action in one to three hours. The onset of action for lispro is 15 to 30 minutes, and peak effect is experienced in 30 minutes to 2.5 hours. Patients are instructed to inject rapid-acting insulin between 15 minutes and immediately prior to taking a meal. Administering sooner can result in profound hypoglycemia.

The major advantage to using rapid-acting insulin is that its action time parallels the action time for most meals. Therefore, when administered at the time that the person begins eating, it will lower blood glucose at the same time that food raises it. In addition, the short duration time means that its action is gone before the next meal begins. This means that less time is spent at high levels and there is less chance of hypoglycemia related to the overlapping build-up with longer-acting insulins.

For patients with diabetes, rapid-acting insulin offers the advantage of greater flexibility in meal and activity planning. Because the injection may be taken as a meal is begun, the user does not have to worry about unexpected delays that could occur during the wait period advised when regular insulin is used. Another advantage is that fewer episodes of nocturnal hypoglycemia are experienced by persons using rapid-acting insulin because the dinnertime dose will normally be out of the system by bedtime.

Short-Acting

Also known as "regular" insulin, this is a clear insulin that is generally used to cover increases in blood glucose associated with the main meals. Onset of action is from 30 minutes to one hour after injection, with peak levels occurring in two to three hours. Persons using regular insulin are instructed to administer a dose between 30 to 45 minutes prior to the meal.

A newer option is inhaled regular insulin administered prior to each meal [114]. In patients who have never taken insulin, the starting dose is 4 units at each meal. However, for persons who have been previously taking injected insulin, the number of units should be calculated based on previous mealtime doses [18]. Inhaled regular insulin carries a black-box warning that acute bronchospasm has been observed in individuals with asthma or chronic obstructive pulmonary disease, and it should not be used in these patients [18,115].

Intermediate-Acting

Neutral protamine Hagedorn (NPH) insulin is a cloudy suspension containing protamine and zinc to prolong the duration of action. Onset of action is one to two hours after administration, with peak action occurring in 4 to 12 hours. Intermediate-acting insulin may remain in the body for up to 24 hours after administration [18]. This type of insulin is frequently mixed with regular insulin and given twice a day.

Long-Acting

Insulin glargine, insulin detemir, and insulin degludec are newer long-acting insulins, providing benefits over their predecessor, Humulin U. The benefit of these agents is their "peakless" action over a 24-hour period, providing a basal pattern of insulin with a lower risk for hypoglycemia. They may be prescribed for once- or twice-daily dosing [18]. Because insulins glargine, detemir, and degludec provide only basal insulin coverage, they are usually used in combination with other insulin preparations or oral agents that will provide mealtime coverage. These insulins cannot be mixed in the same syringe with other insulins [18]. Because glargine is clear insulin with an action profile much different from the rapid- and short-acting insulins, it is dispensed in a vial that is longer and narrower to avoid administration errors. Insulin degludec should not be administered IV or IM or in an insulin infusion pump and should not be used if the solution is viscous or cloudy. The onset of action for both glargine and detemir is about three to eight hours after administration. The onset of action for degludec is about one hour [18].

Fixed Combination

Premixed insulins are available in combinations such as 70% NPH and 30% regular (70/30) and 75% intermediate-acting with 25% rapid-acting (75/25) [6]. Premixed formulas offer convenience to patients and are especially helpful to those who lack the visual, manual, or cognitive skills to mix insulin themselves. The convenience of these formulas sacrifice the potential for optimal blood glucose control, however, as there is less opportunity for flexible dosing based on need. Fixed ratio insulins are usually administered twice a day.

The most commonly used devices for insulin delivery include disposable syringes, insulin pens, and insulin pumps.

Syringes

Disposable plastic syringes are available in several sizes, including 1 cc, 0.5 cc, and 0.3 cc. The 0.5 cc size may be used for dosages of 50 units or less, while the 0.3 cc syringe has the capacity for doses equal to or less than 30 units. Smaller syringes offer several advantages. The major benefit is increased accuracy and reliability when delivering smaller doses because wider line markings are easier to see. Patients should be cautioned to check dosage lines carefully when changing syringes, as some use a scale of one-unit increments while others use a scale of two-unit increments.

Needles of newer syringes are designed for greater comfort to the user. Needles are sharper and thinner than ever before, and they are specially lubricated for comfort. Furthermore, some syringes have shorter needles, which many people find more comfortable. Patients and nurses should keep in mind that changing needle depth could change the rate of insulin absorption. Therefore, patients should consult with their healthcare provider before changing needle length and should monitor blood glucose levels carefully during this time.

The reuse of syringes is a controversial issue. Manufacturers of disposable syringes recommend single use only, while the ADA neither advocates nor prohibits this practice. Reusing needles may benefit some patients financially while helping to reduce medical waste. Recommendations for syringe reuse are intended for people who self-inject and who are capable of safely recapping a needle after each use. People who have poor personal hygiene, are acutely ill, have open wounds on the hands, or have decreased resistance to infection should not reuse their syringes. The ADA provides the following guidelines related to syringe reuse [116,117]:

Administration Procedures

The ADA guidelines for preparing a dose of insulin include ensuring that the hands and injection site are clean and that the cap of the insulin vial is wiped with alcohol prior to dosing. When using cloudy insulins, the vial should be gently rolled between the palms of the hands to resuspend the insulin. Injecting an amount of air into each vial that is equal to the dose of insulin is recommended to avoid creating a vacuum within the vial. When mixing two types of insulin in one syringe, the clear insulin should be drawn first. Air bubbles should be eliminated from the syringe to ensure that an accurate dose is administered [116].

Injection sites for insulin include the subcutaneous tissue of the upper arm, the anterior and lateral aspects of the thigh, the buttocks, and the abdomen, excluding a circle of two-inch diameter around the naval. Site selection will influence the absorption rate of the insulin. Absorption rates are fastest at the abdomen, followed by the arms, thighs, and buttocks. Therefore, it is suggested that the rotation of insulin injection sites should take place within the same anatomical area. For example, more consistent blood glucose levels may be achieved by using the abdominal site for all morning injections and the thighs for all evening injections.

Insulin injections are made into the subcutaneous tissue. Routine aspiration for blood prior to injecting the insulin is not necessary. The angle of the needle during injection should be individualized to avoid intramuscular injection. For most people, a subcutaneous injection can be achieved by grasping a fold of skin and injecting at a 90-degree angle. For those who are especially thin, the tissue should be lightly pinched and an injection angle of 45 degrees should be used [116].

Insulin Storage

The ADA recommends following the manufacturers' guidelines for storage of insulin vials currently in use. The patient should always have a spare bottle of insulin available. Vials of insulin that are not in current use should be stored in the refrigerator. Stored in this manner, they should remain potent until the expiration date [116].

Prefilled Syringes

Prefilled syringes are stable for up to 30 days when stored in the refrigerator. This may be beneficial to those who are sight-impaired or do not have the manual dexterity to fill their own syringes. In these cases, family members, friends, and other caregivers may prefill the syringes on a periodic basis. If possible, syringes prefilled with a cloudy insulin should be stored in a vertical position with the needle pointed up to avoid clumping of suspended insulins in the needle. Prefilled syringes should be gently rolled between the palms prior to injection to warm the refrigerated insulin and to resuspend insulin particles [116].

Insulin Pens

Disposable pens and refillable cartridge-type pens are available. Disposable pens are thrown away when empty, while empty cartridges are replaced in the refillable types. These devices allow the patient to dial the recommended dose of insulin and inject using standard technique. Screw-on disposable needles are available for both types of pens. Advantages of insulin pens are the convenience of portability and not having to fill a syringe from a vial. This benefits active people, working people, travelers, and those who do not have the manual dexterity to fill a syringe from a vial. Manufacturer instructions for some types of pens state that in-use (opened) pens should not be stored in the refrigerator. Patients should be referred to individual manufacturer instructions for proper insulin pen storage. Insulin pen aids should be considered for people with dexterity issues or vision impairment [6].

Newer generation insulin pens are reusable injector pens that come with an intuitive smartphone app to help people with diabetes better manage insulin delivery. This smart system calculates and tracks doses and provides helpful reminders, alerts, and reports. Smart insulin pens come either as an add-on to a regular insulin pen or as a reusable form that uses prefilled cartridges instead of vials or disposable pens [118].

Insulin Pumps

Insulin pumps, also referred to as continuous subcutaneous insulin infusion devices, have been available in the United States for more than 40 years [6]. They are the mainstay for management of type 1 diabetes. Insulin pumps are small, battery-operated microcomputers that resemble a standard pager device in size and appearance. Usually worn on the belt, the pump is connected via a small plastic tube to a subcutaneous catheter inserted through the skin into fatty tissue. The pump is programmed to deliver either a continuous infusion of insulin 24 hours a day, known as the "basal dose," or as a surge, known as the "bolus dose." For the bolus dose, the user programs the pump to deliver a bolus infusion of insulin appropriate to the amount of carbohydrate to be ingested [118].

In 2016, the FDA approved the first automated insulin delivery device for individuals 14 years of age and older with type 1 diabetes [119]. The MiniMed 670G, manufactured by Medtronic, is a hybrid closed-looped system that automatically monitors glucose and provides appropriate basal insulin doses. It measures glucose levels every five minutes and automatically administers or withholds insulin, depending on the level of glucose measured. The system includes a sensor that attaches to the user's body; an insulin pump that is strapped to the body; and an infusion patch that is connected to the pump with a catheter that delivers the insulin. The device requires little to no input from the user [119]. Medtronic's newest iteration, the MiniMed 770G, offers the ability to track glucose levels via a smartphone; the ability for friends and family to view the patient's glucose trends on enabled smartphones; access to future innovations via remote software updates; and patient access to personalized educational content [120].

A major advantage of insulin pumps is the opportunity for tight blood glucose control. This is possible because insulin delivery becomes very similar to the normal physiologic pattern. Pumps also offer the benefit of a more normal lifestyle, allowing users more flexibility with meal and activity patterns.

The ADA provides guidelines for the selection of patients appropriate for pump use [6,121]. Candidates should be highly motivated to take a great deal of responsibility for the care of their diabetes on a day-to-day basis. This includes the ability to count carbohydrate grams, to calculate appropriate bolus dosing, to make adjustments for varying activity patterns, and to monitor blood glucose four to seven times per day.

Adaptive Equipment

Several products are available for people with diabetes who are visually impaired or have other functional limitations. Many of these devices are available in local pharmacies that stock diabetes supplies. Others may be mail-ordered or located through the Internet. An annual resource guide is published in Diabetes Forecast, a magazine for people with diabetes that may be located on the Internet or through the ADA. Local chapters of the Braille Institute can also be contacted for assistance in locating adaptive equipment for the visually impaired. Briefly, some of the more commonly used assistive devices are:

Patient R is a man, 49 years of age, with a 21-year history of type 1 diabetes. He is blind and lives alone without significant support from family or others. He also suffers from diabetic nephropathy and undergoes outpatient dialysis three times a week. He has been receiving home health nursing services for more than three years to assist with diabetes management.

Although Patient R has expressed appreciation for the support provided by the nurses, he is also resentful of their ongoing presence in his life. He longs for more privacy and more control over his own life and asks if there is any way that he can live more independently while maintaining his medical safety. The home health agency sends a nurse with strong diabetes management skills to Patient R's home to assess his potential for increased independence in the management of his diabetes.

Discussion

In her functional assessment, the nurse learns that, with adequate lighting, Patient R is able to see well enough to read a few words of large print with a magnifying glass. Other significant findings from a comprehensive needs assessment reveals that Patient R is able to:

With these abilities in mind, the nurse is able to begin formulating a plan for Patient R. Although he demonstrates the cognitive and manual abilities needed for self-care, his severe visual limitations must be addressed before he is considered safe to manage these tasks on his own.

One area of challenge for Patient R is related to measuring the insulin dose in the syringe. The nurse's initial approach is to observe the patient while he draws an insulin dose using syringes with the largest increment markings available. Because Patient R is on insulin doses of less than 30 units, he is able to practice using a 0.3-cc syringe. Not surprisingly, he is unable to see these syringe markings well enough to draw an accurate dose. Next, the nurse has Patient R try the same syringe using a magnifier. Even with this adaptive aid, he is still unable to consistently draw an accurate dose. The nurse concludes that it will be necessary to make arrangements for the patient's syringes to be prefilled by a sighted person and stored in the refrigerator for later use.

The nurse then considers the type and amount of insulin that Patient R is using. As a matter of convenience, he is using premixed 70/30 insulin, receiving 14 units in the morning and 7 units in the evening. Because he would be injecting different doses of insulin in the morning and evening, it is necessary to ensure that Patient R is able to distinguish between the two differently dosed prefilled syringes. This is accomplished using two glass jars, dissimilar in size and shape, to store the prefilled syringes. Each jar is then labeled in large letters using a bold black marking pen as "MORN" and "EVE." The nurse avoids using the abbreviations "am" and "pm" because of their similarity. She then works with Patient R on a plan to place a predetermined number of prefilled syringes in each jar, with the capped needles facing upward. The patient shows her where and how the syringes should be stored in the refrigerator to maximize his ease of use and minimize potential error.

Patient R's needs assessment has already determined that he is well versed in insulin administration practices. Therefore, the nurse has only to review those techniques with him and verify his competence by having him give a return demonstration. Part of her review includes reminding him to roll the prefilled insulin syringe gently between his palms prior to injection. She also verifies his ability to select the appropriate dose from the jars in the refrigerator and to select an appropriate injection site. She suggests an injection technique of gently placing the needle on the skin before inserting it, rather than using the conventional dart-like approach. This allows him better control over the site of injection.

The next challenge for Patient R is related to blood glucose monitoring. Although he has a meter that he is comfortable using, he is unable to read the results display accurately. The nurse discusses with him the possibility of trying a talking meter. The patient expresses that, because he is already familiar with his current meter, he would prefer to continue using it with a display magnifier if possible. The problem he perceives, however, is that the magnifying glass he is currently using is not sufficient for this procedure. To address this challenge, the nurse refers Patient R to the local chapter of the Braille Institute. Here, specialists are available to supply him with a prescription magnifier that is adaptable for use with his current meter. After receiving this device, the nurse works with the patient to ensure that he is able to accurately read the results displayed on his meter.

Although Patient R initiated these changes in his care because he desired more independence, the transition period is a time of anxiety on his part. After three years of having the security of a nursing visit twice a day, Patient R begins to question his ability to manage safely with less frequent nursing contacts. His concern is validated by the fact that he lives alone and does not have a significant other. It is important at this point to work with the patient and his physician on a plan for future nursing service that would ensure his safety while affording him the independence that he desires. Because he is socially isolated, it is agreed that Patient R should have face-to-face contact with medical personnel once a day. It is determined that outpatient dialysis appointments would meet this need for three days of each week. For the remaining four days of the week, a nurse would visit him at home. The purpose of these visits would be to perform a skilled assessment of the patient's current status and to ensure his medical safety on a daily basis. These nursing visits would include a review of Patient R's blood glucose results using the memory function of his meter. Syringes would be prefilled as needed. Periodically, the nurse would observe the patient performing his self-care procedures to ensure that changes in his functional ability had not occurred. The nursing service would continue to be available to Patient R 24 hours a day by telephone, with additional nursing visits made as needed. A medical social worker is involved in providing the patient with community resources and helping him obtain a diabetes identification bracelet.

This case demonstrates a problem-solving approach to diabetes self-management that promotes the independence of a visually impaired person with diabetes. While issues of medical safety are always paramount, other factors should be considered when developing a plan of care for the visually impaired patient. These factors include the patient's willingness and ability to become more independent, his baseline knowledge, and experience of diabetes self-care and resources available. In the case of Patient R, a safe and viable plan was developed that resulted in greater independence and promoted his sense of well-being.

Although physical activity can provide health benefits to a variety of patients, it does carry some potential health risks for people with diabetes, although the risk varies. For adults with type 2 diabetes, the risk of adverse events from low-to-moderate-intensity activity is low. Because no current evidence suggests that any screening protocol beyond usual diabetes care reduces the risk of exercise-induced adverse events in asymptomatic individuals, the ADA states that pre-exercise clearance is unnecessary, except for individuals who plan to increase exercise intensity or who meet higher-risk criteria. These individuals may benefit from pre-exercise checkup and possible exercise stress test. Routine stress testing is not recommended [122]. To ensure a safe and effective exercise regimen, most adults with diabetes may benefit from working with an exercise physiologist or certified fitness professional proficient in diabetes knowledge.

Patients who use insulin or sulfonylureas are at risk for hypoglycemia during or after exercise if proper adjustments are not made. This is due to the effect that exercise has on lowering blood glucose. People who use meal planning alone to control their diabetes are not generally at risk for experiencing exercise-induced hypoglycemia.

Several factors influence the blood glucose response to exercise, including the timing, amount, and intensity of the exercise. Patients at risk for hypoglycemia are advised to carefully monitor their blood glucose before and after exercise to determine their response to a particular activity. Adjustments to medications and/or food intake can then be made prior to exercise based upon these findings.

The risk for exercise-related hypoglycemia can be reduced if the patient follows a consistent pattern of activity, occurring at about the same time every day and of similar intensity. The following instructions to patients will help minimize the risk for developing exercise-induced hypoglycemia:

General recommendations for people with diabetes who exercise include:

Although most people with diabetes can derive some benefit from exercise, several risk factors may modify their activity plan. The nurse should consult with the physician before discussing an activity plan with patients having any of the identified comorbidities.

Cardiovascular Disease

Silent angina is more common in people with diabetes than the general population. Risk factors include age older than 35 years and diabetes of greater than 10 to 15 years duration. The physician may order a graded exercise test to detect the presence of heart disease before prescribing an exercise program to diabetic patients.

Peripheral Vascular Disease

Patients with this condition, whether of venous or arterial origin, should avoid exercise that may traumatize the foot.

Retinopathy

Patients with proliferative retinopathy should avoid high-resistance exercise, such as lifting heavy weights. They should also avoid activities that produce the Valsalva maneuver and those that require lowering the head below the waist.

Peripheral Neuropathy

Patients with peripheral neuropathy should avoid weight-bearing exercise that can cause orthopedic stress to the foot. They should also avoid activities that may cause mechanical trauma to the skin of the lower extremities. Such activities include prolonged walking, jogging, or step exercises. Recommended exercises for those with peripheral neuropathy may include swimming, bicycling, and chair exercises [122].

Exercise and the Elderly

Elderly people without significant physical limitations can generally participate in the same types of activity as younger people, as long as it is approved by the physician and is modified to meet the needs of the individual. For seniors who are currently sedentary, it is recommended that they add a few minutes of increased activity each day and gradually build up to an accumulated 30 minutes of physical activity. For those without significant functional limitations, this may include light housework and short walks. For seniors who are already moderately active, appropriate exercise may include a paced walking program, low-impact aerobics, or swimming. As with younger people, elderly patients require education about the risks and benefits of exercise and instruction on prevention and treatment of exercise-induced hypoglycemia.

Activity programs can be designed to meet the needs of elderly people who have varying degrees of physical limitation. For example, for a person who is chair-bound, chair exercises may be appropriate. These may include "marching" in place or repetitively reaching toward the ceiling with the arms. Resistance can be added by holding 6-ounce soup cans or paper plates during the exercises. There are several commercially available videotapes for senior chair exercises that include music and demonstrations.

Multiple and complex pathologic processes are involved in the development of diabetic foot disease. The presence of three specific conditions, peripheral sensory neuropathy, vascular disease, and immune deficiency related to elevated blood glucose, is implicated in the majority of cases. These risk factors make the diabetic foot more vulnerable to mechanical stresses that can lead to skin breakdown and poor healing [125]. Diabetic foot amputations are often precipitated by minor preventable foot trauma, such as a blister from poorly fitting shoes or inappropriate care of toenails. If sensory neuropathy is present, the patient may not perceive that an injury has occurred. When the neuropathic wound is complicated by vascular disease, serious problems with wound healing may result. The environment provided by a poorly healing wound then presents significant opportunity for an infectious process to develop. This opportunistic environment can be further complicated by impaired host defenses when blood glucose is elevated.

Although diabetic foot ulcers should always be taken very seriously, proper wound management can heal many foot ulcers. All ulcers should be thoroughly evaluated to determine etiology and course of treatment.

The value of preventive foot care cannot be overestimated. Preventive care includes daily self-foot exams, proper foot care, proper footwear, and regular foot exams by a healthcare professional.

Daily Self-Foot Exam

Patients should be instructed in how to perform a daily foot exam. A return demonstration should be requested to ensure that the patient is able to reach and see the bottoms of the feet. The self-foot exam includes inspection of the tops, bottoms, and sides of each foot and between the toes. A mirror can be used to see less accessible areas of the foot if necessary. Family members or caregivers may need to be involved. Patients should seek prompt professional advice for any foot problems including corns, calluses, open areas, nail deformities, or cracks and fissures in the skin.

Proper Foot Care

Foot care for people with diabetes includes keeping the feet clean and dry and avoiding trauma to intact skin. Feet should be cleansed daily, but not soaked, and dried well, especially between the toes. Unscented, non-alcohol-based moisturizing lotions are recommended to keep the skin soft and supple. Avoiding lotion between the toes prevents excessive moisture build up that could promote the development of fungal infections.

Trauma to the foot can be avoided by wearing well-fitting protective footwear at all times. People with diabetes should be instructed to check the insides of shoes for foreign objects before putting them on. Feet should be inspected immediately after wearing new shoes for areas of pressure or blisters. Clean, well-fitting socks that do not wrinkle or bind are recommended. Other footwear recommendations include [127]:

Clinical Foot Exam

The ADA recommends that people with diabetes receive a thorough clinical foot exam by a qualified healthcare professional at least once a year [6]. Patients with high-risk conditions, such as loss of protective sensation, structural abnormalities of the feet, and compromised vascularity, should have their feet examined at every office visit [6].

The annual clinical foot exam should include sensory testing with a monofilament to detect loss of protective sensation. This is a simple and noninvasive method for identifying feet that are at risk for problems that could lead to amputation. The test is done using a monofilament that resembles the bristle of a hairbrush. The monofilament is pressed onto specific areas on the plantar surface of the feet while the patient has his or her eyes closed. The patient then indicates whether or not the monofilament is felt, indicating the presence or absence of protective sensation. When protective sensation has been lost, there is an increased risk for amputation and the patient should be counseled on the importance of vigilant preventive measures. In some cases, custom-fit shoes are required for those who have lost protective sensation [6].

Physiologic stress, such as concurrent illness, infection, surgery, or trauma, can disrupt homeostasis and lead to loss of blood sugar control in the person with diabetes. All patients with diabetes should be educated with regard to the risks involved during illness. This should include instruction on appropriate sick day management, as previously noted.

While minor illness can usually be managed safely at home through telephone contact with a physician, certain conditions will require the immediate attention of a healthcare provider [6]. These include:

Psychologic stress in general can also have an undesirable effect on blood glucose control, in many of the same ways as physiologic stress. General psychologic stress can be brought on by significant life events, such as the death of a spouse, changing jobs, or dealing with a loved one's illness. It can also be related to other life factors, such as economic hardship, pressures at work, interpersonal relationships, or family dynamics.

One way of mediating the negative effects of stress on health can be to limit the number or intensity of stressors that one experiences. Because this is not always possible, learning how to cope with stress is another way of curbing its adverse effects upon health.

Certain techniques and behaviors can be encouraged to help the patient cope with stress. Keeping a stress diary may help some patients identify events that can trigger the stress response. Patients can use their blood glucose logs to keep track of stressful events and feelings. Correlating these events and feelings with blood glucose results may help the patient monitor the effect of stress on blood glucose control.

Another suggestion for reducing stress is to help patients prioritize the demands in their lives. By doing this, the person may be able to realize that some things are of less importance and can be given up or delegated to someone else. By doing fewer things, it is more likely that the person can address the more important tasks fully and will experience a greater degree of satisfaction.

Directing stress-related energy toward something more positive is also advocated as a technique for reducing stress. Activities that may effectively reduce feelings of stress include engaging in exercise, hobbies, or other pursuits of interest.

Techniques such as progressive relaxation and guided visual imagery are generally accepted as effective stress-reduction methods. Several audio tapes and books are available that provide scripts for delivering these techniques. Furthermore, many professional therapists utilize these methods, and they should be recommended when the patient does not have the resources for dealing with stress on his or her own.

In addition to the general stressors that most people face, people with diabetes experience specific feelings, frustrations, and emotional struggles that can be directly related to having the disease. This so-called "diabetes-burnout" is believed to be very common. Feelings frequently reported by subjects with diabetes have included guilt or anxiety for not always following the treatment plan and worry about the possibility of serious long-term complications. Other feelings related to having diabetes include helplessness, depression, anger, and being overwhelmed. These difficult feelings about diabetes along with poor coping skills are believed to be among the greatest obstacles to satisfactory self-care [44].

"Diabetes distress" is a term used to describe the psychologic effects (worries and fears) of patients with diabetes. It is distinct from other psychologic disorders [6]. It is associated with poorer health and is most common in those who use insulin [128].