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Guidelines for Diabetes Care

Guidelines for diabetes care have been developed, based on the Tayside Diabetes Handbook, for district nurses to ensure that people who are housebound will receive equity of care, comparable with those who attend their local GP or Diabetes Clinic. These guidelines have been adapted from current research and recommendations for good practice.

CONSIDER a diagnosis of diabetes in a patient with:

• thirst and polyuria
• unexplained weight loss or tiredness
• pruritus vulvae, balanitis or recurrent 'UTI's'
• recurrent infections
• blurring of vision (usually an osmotic effect and not permanent)
• discoloured or ulcerated feet
• hypertension, ischaemic heart disease or stroke
• obesity, with diagnosis of arterial disease or family history of diabetes.

In such patients, it is useful to perform preliminary screening investigations i.e. random plasma glucose measurement and urinalysis for presence of glucose and ketones. The diagnosis of diabetes has important medical and legal implications for the patient.

Therefore a diagnosis of diabetes should not be based solely on the finding of:

• glycosuria
• raised blood glucose (finger prick sample) on a 'stick' reading
• elevated haemoglobin A1c (HbA1c) result.

The World Health Organisation has recently published revised guidelines on the diagnosis of diabetes. Diabetes UK recommends that all UK health care professionals adopt these new criteria from 1st June 2000.

If ketonuria is present with:

• Severe symptoms i.e. vomiting and dehydration, urgent hospital admission is required.
• Milder symptoms and weight loss discuss patient urgently with the diabetes team for consideration of insulin therapy.

People with a high risk of Diabetes

• Obese patients, especially abdominal obesity.
• Children who are obese.
• People of Asian, African or Afro-Caribbean origin.
• People over 65 years.
• Family history of diabetes or cardiovascular disease.
• Women with a history of gestational diabetes or given birth to a large baby (>4kg).
• People on long-term steroid therapy.

THE ROLE OF THE ORAL GLUCOSE TOLERANCE TEST (OGTT)

Agorithm for Diagnosis of Diabetes

1. Classical symptoms (e.g. polyuria, polydipsia, unexplained weight loss) plus one of the following
   • random plasma venous glucose concentration > 11.1 mmol/L
   • fasting plasma venous glucose concentration > 7.0 mmol/L
   • plasma venous glucose concentration > 11.1 mmol/L (2 hour sample in OGTT)
2. No symptoms i.e. incidental finding of glycosuria or hyperglycaemia
   • Diagnosis should not be based on a single venous plasma glucose measurement
   • Additional testing on another day with a value in the diabetic range is essential (using either fasting, random or samples taken 2 hours following glucose load)
   • If fasting or random values are not diagnostic, the 2-hour value should be used
3. If ketonuria is present with:
   • Severe symptoms i.e. vomiting and dehydration, urgent hospital admission is required.
   • Milder symptoms and weight loss discuss patient urgently with the diabetes team for consideration of insulin therapy.

Definitions of Diabetes

Type 1:

Absolute deficiency of insulin due to pancreatic beta-cell destruction. Most commonly presents acutely before age of 35 but can occur at any age. Insulin dependent.

Type 2:

Deficiency of or insensitivity to insulin. More common in those over age of 35 but can occur in younger (especially obese) patients. Although the onset of type 2 is less dramatic both types have the same risks of developing microvascular and macrovascular disease.
Type 2 is a progressive condition therefore there are many people who are currently diet or tablet controlled who may eventually progress onto further treatments, possibly insulin. It is essential then to identify those existing patients on the district nursing caseload who may potentially progress to oral medication and/or insulin. Frequency of reviews for these patients in relation to risk factors and complications may need to vary.

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