AIMS & OBJECTIVES
To improve the quality and duration of life of
people with diabetes
- By the maintenance of near normal blood glucose
- By the reduction of risk factors such as smoking,
obesity, hyperlipidaemia and hypertension.
- By the early detection and treatment of
- By the early diagnosis of diabetes
- To educate and empower the patient to achieve
both psychological as well as physical well being
- To educate members of the Primary Health Care
Team (PHCT) caring for patients with diabetes and
to evaluate its effectiveness.
- Practice Nurses
- to have post basic training in diabetes care -
ideally ENB 928 or Diploma in diabetes care
- will undertake clinic annual reviews and 3 &
6 monthly checks.
- the education and monitoring of newly diagnosed
- P.N.s with specialist training may advise on dose
levels of insulin/therapy if they feel competent
to do so
- Sister Smithson - the organisation of diabetes
care within the surgery and for domicillary care,
liaising with all other professionals concerned,
D.N.s, optician, dietician, chiropodist, G.P.s.
- to have responsibility for individual patients
who are registered with them.
- will undertake the review of patients following
their clinic appointment, will make alterations
to therapy as appropriate, refer on as necessary
to secondary care.
- Cardiovascular - Smoking
- Nephropathy - micro- albuminuria, albuminuria
- raised creatinine levels
- Neuropathy - reduced sensation, vibration
- Peripheral vascular disease - reduced peripheral pulses
- Complications associated with Diabetes
- Visual Impairment - retinopathy
- Ischaemic Heart Disease - angina, myocardial infarct,
- Renal Failure
- Normal weight for height (BMI near to 25.0)
- Diet - healthy eating. Half dietary intake should consist
of carbohydrates (preferably complex); reduce sugary
foods; reduce fats (particularly saturated poly
unsaturated fats; reduce salt; alcohol in moderation.
Special Diabetic foods are not recommended.fat)
- replace saturated fats with mono or
- Exercise - at least 3 half an hour walks per week, or a
level of exercise that is appropriate.
- Smoking - STOP
This should not be attempted in one visit - small amounts at a
time backed up with literature. Enter into notes all that has
- A pot filling, didactic approach does not work.
- What does the patient know, what are their fears, what do
they need to know, what is their level of understanding.
- Try to be empathic, sit back and allow the patient to ask
An adult needs to know:
- Why they need to know it - the reason behind, its
relevance to diabetes.
- Many need to feel in control of decisions and their lives
and not to be told what to do. They tend to resist others
imposing their will upon them.
- Their past experiences and health beliefs will influence
- They have to be ready to learn, and not still in
shock from the diagnosis
- It needs to be relevant to them and the lives that they
- They need to know what they will gain from complying
Areas to be Covered
- Driving - it is a legal requirement that all people with
diabetes inform their insurance company, if they fail to
do so they may not be covered if they are involved in an
accident, even if they are the innocent party. If on
tablets or insulin they need to inform DVLA. If on
sulphonylureas (e.g. gliclazide) or insulin need to be
aware of the danger from hypos. Dont miss meals.
Test blood. Carry snacks. Stop driving immediately if
- Explanation of Diabetes - aetiology- cause and
relationship between food, treatment and control. Effects
of exercise & illness. Important to address the
psychological aspects and patients concerns. Ascertain
patients knowledge base and answer questions rather
than pot filling with advice.
- Type 1 - insulin deficient Treatment and
effect of pills/insulin - most
- Type 2 to start on diet only.
- Diet, Exercise and Alcohol - all patients to be referred
- DAMES = Diet, Acarbose, Metformin, Exercise,
Suphonylureas - stepped care
- if obese - 6 months trial of diet
- on-obese and raised blood glucose and/or
symptomatic - ? drug therapy
- If to start oral hypoglycaemics - choose suitable
Diet only trial for 6 months. If BMI>30, then
metformin (take after food) (<70yrs) or
acarbose (>70yrs), otherwise gliclazide (take
30min before food).
- discuss side effects - Acarbose
- (take with food) indigestion, flatulence
- Metformin -
(take after food) gastric disturbance, metallic
taste, diarrhoea, bloating, nausea, loss of
- (take 30 mins before food) Hypos, weight
- Self Monitoring -
Type 2 usually only need to test their urine - 2
hours post prandial. Explain relationship between
glycosuria and food intake and exercise levels. Use as
education tool as well as for monitoring control.
Type 1 to do BMs. Usually started off in hospital and
most under secondary care or shared care. Test before
meals and bed. Best to do blood series (4 times
throughout the day), then rest for a few days unless
needing to do extra for symptomatic monitoring e.g. extra
exercise, different food intake, alcohol, unwell,
- Reasons for good control - well being (feel better, less
tired), prevention of complications.
- Illness - do not stop treatment. Type 1 frequent
monitoring, check ketones, ? extra insulin, maintain
carbohydrate intake (in liquid form if necessary),
maintain fluids. If necessary - Contact GP SOS.
- Identification - Bracelet or card
- BDA - encourage joining the British Diabetic Association
(give application form).
- Eyes - Importance of annual check up with opticians. Will
be given a form to take to opticians at every annual
If newly diagnosed - do not get new glasses until
diabetes is controlled (6 months) or could waste
Note rapid lowering of blood glucose can damage the
- Foot Care - Young and capable, without problems - can
look after their own feet - after receiving instructions
on foot care, dangers, breaking in new shoes, and to see
nurse if any problems. Others - refer to
chiropodist (and give hygiene instructions etc. with
- Free prescriptions - if on treatment involving diabetic
drugs or insulin, eligible for free scripts.
- Blood Glucose between 4 - 8 (tight control - discuss
extra risks of hypos and driving)
- Blood Glucose between 4 - 10 (acceptable control
particularly in older patients)
- HbA1c 7.4 or less (acceptable control) Note this
reference range is for acceptable control not good!
- Cholesterol < 5.2
- B.P. < 140 systolic; 85 diastolic
- BMI 25
- Creatinine in normal reference range
- Urine - no protein present
- Urine - if patient has normal renal threshold, then blood
glucose will be greater than 10 mmol if glucose is
present in urine. Therefore in normal circumstances there
should be no glycosuria - however, note high or
low renal thresholds: urine testing is for education and
as a guide only.
- Improved diabetic control can reduce complications in
both Type 1 diabetes (DCCT 1993) and Type 2 diabetes
- All patients with diabetes under PHCT care will be
invited to attend an annual review, the target for
achievement is 100%.
- All patients with > 7.4 HbA1c or with risk factors or
complications and all newly diagnosed patients to have 3
- All patients with HbA1c >6.8 to have 6 monthly checks
- All patients with HbA1c 6.8 or less may be considered for
annual review if the results have been stable for more
than a year, the patient knows to self refer if home
monitoring shows glycosuria or they feel tired, unwell or
Use diabetic annual review sophie
Every patient with a diagnosis of diabetes should receive an
- To understand the aetiology and treatment of diabetes
- Discuss well being and home monitoring results
- Patient's needs and concerns
- Revise and update education
- Improve control
- Prevent complications by targeting risk factors e.g.
smoking, lipids etc.
- Address any other areas of concern or need (refer on if
- Perform screening tests and make referrals.
- Scale and height measure
- Urine testing strips
- Tuning fork
- Referral forms
- Venepuncture equipment
- Welcome and check identity of patient and gain informed
- Urine - glucose protein (if present check MSU to exclude
UTI, ? for 24 hour protein) Type 1 or Type 2 < 60
micro albuminuria to lab (EMU)
- Habits - ? Smoking ? alcohol intake
- Feet - test for pulses (quality and quantity); vibration
and sensation; condition; pain.
- Eyes - give appointment for retinal camera and ask
patient to take see optician.
- Compliance - correct tablet/insulin regime (Injection
- Diet - relate to home monitoring results
- Exercise - encourage within capabilities.
- Blood Tests HbA1c; U&Es; Cholesterol; (LFTs if on
Metformin or Acarbose) TFT at 3 yearly intervals. (others
in felt necessary ? symptoms e.g. FBC)
- Symptoms - angina, claudication, breathlessness, hypos
& side effects of drugs etc.
- Educate & Empower. Discuss targets patient would like
to achieve, changes in treatment and why - possible side
effects and implications (if male- don't forget potential
problems such as impotence).
- Record all findings and points covered in notes and
patient's 'Care Card'.
- Ask to make appointment with GP in 2 weeks time for blood
results 16) complete referral forms e.g. dietician and
- Update computer recall
- Well being and home monitoring results (same objectives
etc., as for annual review)
- HbA1c; B.P.; Weight; compliance.
- Address patients needs and concerns
- Complete records
- Update Care Card and computer
- To make appointment in 2 weeks time with GP (or
specialist nurse if well controlled) for results
- Discuss with patients - their concerns and well being
- Check nurses findings and if appropriate re-examine
- Discuss patients targets in relation to laboratory
- Alter therapy if necessary
- Consider aspirin for all patients over 40 with additional
risk factors - use Framingham
calculator to determine risk over 3%
- Target risk factors - add hypotensives, lipid lowering
drugs, aspirin etc.
- Treat complications
- Address any other concerns
- Discuss future targets
- Refer to secondary care if necessary
- Update notes and alter recall markers if felt necessary
- Update patients care card with blood results
- DCCT 1993 Diabetes control and complications trial New
England Journal of Medicine Vol 329 No 14 p 972-986
- Guillausseau, P et al 1998 Glycaemic control and the
development of retinopathy in Type 2 diabetes mellitus: a
longitudinal study Diabetic Medicine Vol 15 No 2 p
22 January 2012