Diabetes can be a lifelong condition that affects the body’s ability to use the energy contained in food. There are 3 types of diabetes, Type One, Type Two and Gestational.
The common factor involved in all three types is that the Insulin required to utilize glucose is either inadequate or unavailable. The hormone Insulin is required to enable the body’s cells to take in and utilize glucose. Without this hormone, high levels of glucose can accumulate in the blood stream, resulting in damage to the tiny vessels in the eyes, heart, kidneys and nervous system.
I will give a brief description of the other two types of diabetes. Type Two is, by far the most common, especially in patients in Long Term Care (LTC) facilities
In Type One diabetes, the hormone Insulin, secreted by the pancreas is not available. Studies show there may be two reasons for this: (1) the body may produce antibodies that damage the pancreas and therefore it is unable to produce insulin or (2) there may be a genetic disposition that result in faulty beta cells that are unable to make Insulin.
Gestational diabetes is triggered by pregnancy and usually abates with childbirth. It can, however, put the mother at risk for developing Type Two diabetes later in life.
Type Two diabetes was previously called adult onset diabetes. However, it is now occurring in much younger people. If left untreated, it can eventually cause heart disease, stroke,kidney disease, blindness and nerve damage (neuropathy).
There is no cure for diabetes but it can be controlled with good nutrition, weight management and exercise.
Type Two diabetes occurs when the pancreas does not produce enough insulin or the insulin cannot be used appropriately by the body’s cells (insulin resistance) or a combination of both.
Statistics from the American Diabetic Association (ADA) indicate that 25% of residents living in LTC facilities have Type Two diabetes. Of this number, 80% of patients have cardiovascular disease, 56% have hypertension and 70% have 2 or more other chronic conditions, such as, chronic kidney disease (CKD), coronary artery disease (CAD) and stroke.
Studies in Great Britain have shown that by keeping the Hemoglobin AIc levels of blood below 7, preferably at 6.5, the risk of these diseases occurring, are drastically reduced. When hemoglobin joins with glucose in the blood it becomes “glycated”. By measuring the “glycated” blood (HbA1c) clinicians can get an overall picture of the average blood glucose concentration over a 3 month period. In people without diabetes the level is 6 or less. For good control in diabetics it should be maintained at 7 or below. This test is taken a few times a year and can be used to monitor the effects of diet, exercise or medication.
In LTC facilities, the residents with Type Two diabetes, will decline in health if not treated. Dehydration, depression, confusion, eye problems, foot ulcers, neuropathy, and recurrent infections, slow healing wounds and decline in performing the activities of daily living (ADL) will be present if the diabetes is not controlled. This control is individualized according to the patient’s condition.
Many factors associated with aging can affect glucose metabolism in older adults. Selecting the correct medication based on these factors can be difficult. Some of these factors include, increased adipose tissue and decreased muscle mass. Alteration in food intake and ability to exercise. Insulin resistance in the cells, co-morbid health conditions and drug interactions. Some psychosocial factors include stress and depression. As most of LTC residents are admitted with a history of type two diabetes of many years duration, the medical staff need to be aware of the disease processes already present.
As always, the resident and family need to be involved in discussing how aggressive treatment (diet, exercise, blood testing and medication) will be. The ADA has very good information on all issues pertaining to appropriate treatment. The hands-on care staff must follow the physician’s orders and be aware of the resident’s plan of care.
Blood sugar control is the key to good diabetes management. Preventing episodes of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) is of the utmost importance. Be aware of the parameters provided by the laboratory and follow the facility guidelines for treatment.
Hypoglycemia occurs when the blood glucose levels are at 70 mg/dL or less. Signs or symptoms include:
Weakness or tiredness
Hunger
Dizziness or feeling shaky
Sweaty
Rapid pulse
Blurred vision
Unresponsiveness
The main reasons for hypoglycemic episodes are:
skipping a meal or consuming too few carbohydrates,
increased physical activity and some medications. A long time interval between taking insulin diabetes medications and eating can also cause hypoglycemia.
The best way to treat this illness is to be prepared. Follow the facility guidelines and know where the necessary equipment is stored. Nurses need to be aware of residents with dementia who also have diabetes. These residents are unable to recognize or discuss symptoms and must be monitored carefully. Parameters must always be available for administering insulin and other diabetes related medications. Physician and family must be notified of any episodes that may occur and these must be included in the nurses’ documentation in the clinical record.
Once again, I will say how important is good communication. “How do you feel this morning” can provide a wealth of information. The resident may not know why she is shaky, sweaty or thirsty, but we do and if she is a diabetic, we should test her blood sugar levels.
Hyperglycemia occurs when there is a high level of glucose in the blood. Some laboratories indicate a fasting blood sugar greater than 130 mg/dL as hyperglycemic.
S/Ss usually include increased thirst, headache,frequent urination, blurred vision, fatigue and weight loss.
May occur when an insulin dose or prescribed diabetes medication is omitted, consumption of high carbohydrate meals, an infection or illness and some medications (steroids) may produce hyperglycemia.
Blood sugar monitoring is ordered by the physician and should be performed exactly as prescribed and the results documented in the diabetic flow sheet immediately after testing.
Accu-chek Meters. There are many different types of meters in use for testing the levels of glucose in blood. The nurse must become familiar with the type used in the facility and must follow the policy for care, infection control and privacy during testing. An abnormal reading, high or low, should be followed by a nursing intervention.
Always refer to the physician’s orders and document.
It is very important that there is a limited time lapse between testing and administering the prescribed insulin or medication and between the medication and food intake. By being consistent and observant, our residents are kept more safe and our workload is made lighter by preventing complications.
