Diabetes is a disease which has a significant impact on individuals, family and society (DH, 2002). It affects 1.4 million people across the UK (Hilton and Digner, 2006). Such is the significance of the disease for the National Health Service (NHS) and other resources and services, that the Department of Health published the National Service Framework (NSF) for Diabetes in 2002, setting standards for the diagnosis and management of diabetes (DH, 2002).
Diabetes is separated into different types and presentations of the disease. Diseases are characterised by high blood glucose due to a lack of insulin or impaired response to insulin (DH, 2002). In Type 1 Diabetes, the pancreas does not produce insulin because the cells which produce it, Beta cells in the Islets of Langherhans, have been destroyed by the body’s own immune system (DH, 2002; Watkins, 2003). This is the form of diabetes which will be dealt with in this case study. Type 2 diabetes is associated with older age of onset, and is characterised by reduction in insulin production and a degree of insulin resistance (Watkins, 2003).
The patient, G, presents at 4am via paramedic ambulance at the Accident and Emergency department following collapse at her place of work. G is 23 years old, and was diagnosed with Type 1 Diabetes 8 months ago. She has been prescribed twice-daily insulin and diet modifications but is known to be non-compliant with this regime and has presented previously to diabetic clinic with worsening complications including loss of vision due to diabetic retinopathy. This is due to her commitment to maintaining her pre-diagnosis body image and also due to lifestyle factors. She studies health and beauty at a local college, and also works late nights at a gentleman’s club. She has not coped well with her diagnosis of Type 1 diabetes, being a hitherto independent young woman who travelled the world.
On admission, G is unconscious, and her hospital record identifies her as diabetic. Her symptoms suggest either acute hypoglycaemia or Diabetic Ketoacidosis (DKA). Hypoglycaemia in Type 1 Diabetes is usually due to an overdose of insulin, lack of carbohydrate intake, excessive exercise, or a combination of any of these factors. DKA is a potentially life-threatening condition caused by an inadequate concentration of insulin in the blood (DH, 2002; Hankin, 2005). As a result, the body’s cells cannot use glucose for energy and instead draw on the body’s fat reserves, causing blood glucose to rise but also causing an increase in ketone bodies, the by-products of fat metabolism (DH, 2002).
There are two distinct sets of clinical needs in this case. Watkins (2003) states that the needs of the diabetic patient are: save life; alleviate symptoms; prevent long-term complications; reduce risk factors such as smoking, hypertension, obesity and hyperlipidaemia; educate patients and encourage self-management. Initially, G needs immediate resuscitation, stabilisation of her diabetes and diagnosis and treatment of all aspects of her current condition.
While it is logical to assume from her past history that this is DKA related to insulin omission, DKA could also be precipitated by other conditions such as infections or myocardial infarction (DH, 2002). This is due to the body response to physical or biological stress, resulting in, for example, a hypermetabolic state with alterations in carbohydrate metabolism (Turina et al, 2006). Endocrine reactions to stress cause increased levels of catecholamines and glucocorticoids, both of which precipitate hyperglycaemia (Turina et al, 2006). Therefore the diagnostic phase must include investigation for concomitant or precipitating illness, because the cause must be treated in order to achieve full glycaemic control.
The initial findings are more suggestive of DKA. An immediate blood glucose test is carried out on admission using a standard Glucometer, and is found to be 1.3 mmols. The normal range of blood glucose is 4-7 mmols. This finding is consistent with hypoglycaemia. The risk of severe hypoglycaemia is higher in patients receiving insulin therapy (DH, 2002). The brain is dependent on a constant supply of glucose as its main source of energy, and so hypoglycaemia can affect brain function, leading to confusion, fits, coma and even death (DH, 2002). G’s pallor is consistent with hypoglycaemia (Guthrie and Guthrie, 2004). Blood pressure is elevated at 150/90 mmHg, pulse is strong and rapid at 110 bpm, and pupils are dilated, all symptoms consistent with hypoglycaemia (Guthrie and Guthrie, 2004).
Diagnosis of coma is achieved through use of the Glasgow coma score – which on admission is 3. G is unresponsive to pain. Immediate resuscitation involves the following distinct phases and should be in line with an evidence-based hypoglycaemic management protocol (DH, 2002; Edge et al, 2005; Hankin, 2005; Hilton and Digner, 2006):
The immediate treatment is the introduction of glucose, either by intravenous bolus injection of 50% glucose or by intravenous injection of glucagon. Both work by raising blood glucose, thus reversing the neurological effects of hypoglycaemia.
Observations and diagnostic tests
Blood pressure, temperature, pulse and respiration rate are recorded via continuous telemetry. And ECG is taken to rule out myocardial infarction. Blood tests include Full Blood Count, Liver Function Tests, Urea and Electrolytes (Hankin, 2005). Prothrombin Time and Clotting Factors may also be tested, due to the risk of disseminated intravascular coagulation. The following will also be tested:Glucose (blood, urine); HbA1c; Fructosamine; Ketones (urine); Urinary albumin excretion; Creatinine / urea; Proteinurea; Plasma lipid profile (Reinauer, 2002). The simplest indicator of the adequacy of carbohydrate metabolism of a patient is the blood glucose Concentration, but glucose is rapidly metabolized in the body (Reinauer, 2002). This suggests that blood glucose reflects the immediate status of carbohydrate metabolism, but does not allow a retrospective or prospective evaluation of glucose metabolism (Reinauer, 2002). Neurological observations should be carried out regularly and trends monitored alongside other vital observations (Guthrie and Guthrie, 2004).
A Guedel airway has been inserted during transit, but the client is otherwise not in respiratory distress. Oxygen saturation is measured via digital probe and is found to be 100% on 2L Oxygen via facemask. Intubation is not considered at this point.
Immediate intravenous access with two large-bore IV cannulae is necessary. Depending on G’s condition and peripheral vascular status, it may be necessary to insert a central line, which would serve the dual purpose of allowing accurate blood pressure measurement and the introduction of fluids and medication.
Continuous IV insulin has been found to be the most effect means of maintaining glycaemic control in the setting of the often variable clinical and metabolic status (Watkins, 2003). Continuous intravenous insulin is commenced utilising a standard solution of 100 unit human insulin to 100 ml saline delivered by a syringe driver. The solution is mixed and checked by two qualified staff prior to commencement. The rate is set at mls/hr dependent upon hourly blood glucose measurement with glucometer.
IV Fluid Therapy
IV fluid therapy needs to be strictly monitored, and for this reason, fluid balance must be accurately measured. A urinary catheter (indwelling) is be inserted. Urine may be sent for microscopy, culture and sensitivity at this point as hyperglycaemia may result in pyuria due to the presence of glucose allowing rapid proliferation of bacteria. A urinary tract infection could be a precipitating disease and so must be tested for, and given G’s non-compliance with disease management it is likely she may have periods of hyperglycaemia leading to such complications. At the same time, a urine specimen is tested by ‘dipstick’. IV fluids may be both hydrating 0.9% Saline and an infusion of 5% or 10% glucose via infusion pump to allow titration of insulin therapy on an hourly basis. The hydration regime should be managed in conjunction with close monitoring of electrolyte levels (Guthrie and Guthrie, 2004).
Place of Care
The first 48 hours should be managed in a critical care facility. Whilst in the intensive or high dependency unit, G’s condition should be approached using an integrated, holistic approach, focusing on maintaining homeostasis and blood glucose (Place and Phillips, 2005). Following this, G should be transferred to a medical ward under the care of a diabetes specialist for ongoing monitoring, health education and treatment. Once neurological status has been established, a full history should be taken (Krentz, 2004).
Care should be managed by a specialist team in line with established, agreed care pathways (Pollom and Pollom, 2004). If all professionals within the team and those in liaison with the team follow the National Service Framework, the implementation of an integrated approach across hospital and community services should be achievable (O’Brien and Hardy, 2003).
Once stabilised, G should be returned to her normal insulin regimen with balanced dietary intake. Blood glucose monitoring and insulin administration will be carried out by healthcare staff initially. A plan of care should be developed to address G’s need holistically (Collis, 2005), with the specific aim of improving her current condition and instigating programmes to improve future glycaemic control, concurrently reducing her risk of long-term complications of her condition (Watkins, 2003).
Complications of diabetes in the long term are life threatening and associated with serious morbidity. Macrovascular complications, such as atherosclerosis increase the risk of coronary artery disease and cardiovascular accident (Guthrie and Guthrie, 2004; Bloomgarden, 2005; Soedmah-Muthu, 2006). Diabetic retinopathy can lead to blindness (Guthrie and Guthrie, 2004). Neuropathy can lead to gastrointestinal disturbance, peripheral vascular disease, ulceration and erectile dysfunction in males (Guthrie and Guthrie, 2004). Glycolysation in the kidney leads to glomerular damage and eventually irreversable kidney failure (Guthrie and Guthrie, 2004).
Condition Management Review
Given G’s history and a recent diabetic emergency, the diabetic team may decide to review their management of G’s diabetes. There may be alternative treatments which could enhance her quality of life and reduce the risk of recurrent diabetic emergencies. She may be a candidate for a continuous subcutaneous insulin pump or for even more controversial therapies such as nasal insulin (Snow, 2006). While the National Institute for Health and Clinical Excellence (NICE) has not approved inhaled insulin for general use, pilot studies demonstrate its efficacy in some cases of both Type 1 and Type 2 diabetes (Snow, 2006). However, this therapy may not be suitable for G’s busy lifestyle as she would still need to take regular injected insulin combined with this therapy, and also because her issue is not hyperglycaemia in this instance, but hypoglycaemia.
Therefore, a continuous subcutaneous insulin infusion pump may be the solution (NICE, 2007). Lee et al (2004) demonstrate that this approach is both safe and effective in achieving better glycaemia control for clients with ‘fragile’ diabetes. The pump system provides the closest approximation of natural insulin secretion by providing a continuous rate of infusion which can be adjusted by the client throughout the day, based on self-assessment of blood glucose, diet and activity levels (Lee et al, 2004). The pump infuses insulin over 24 hours with facilities for preprandial boosts (Watkins, 2003). Pump therapy allows clients to achieve not only better glycaemic control, but the ability to lead a more normal life, providing flexibility of, for example, mealtimes (Lee et al, 2004).
In considering a holistic approach, this therapy is particularly suitable for G’s lifestyle as it would allow the flexibility she needs. Lee et al (2004) cite some of the reasons for initiating the system, including poor glycaemic control, a need for flexibility and lifestyle and a history of hypoglycaemic events requiring assistance. The system is associated with high rates of satisfaction and compliance (Lee et al, 2004). However, this therapy is not always available in every NHS trust in the UK, and G will need to be educated in its use, for example in rotating cannula sites, and also given ongoing support to ensure proper self-management and compliance. Research has demonstrated that training in intensive insulin management improves both glycaemic control and quality of life for patients with Type 1 diabetes (DAFNE, 2002), and it would be logical to assume that if the multi-disciplinary team can demonstrate to G some improvements in her quality of life, she might be more likely to be compliant with diet and insulin regimes.
Another component of the condition review is liaison with ophthalmic services and review, assessment and management of her diabetic retinopathy. In diabetic retinopathy, vascular damage weakens the walls of the blood vessels causing microaneurysms and leakage of protein into the retina (Guthrie and Guthrie, 2004). This leads to blockage of the retinal vessels, and eventually retinal ischaemia (Guthrie and Guthrie, 2004). In response, the retina stimulates growth of new vessels, which are thin and friable and prone to breakage, causing micro-haemorrhage into the retina and vitreous humour, affecting vision (Guthrie and Guthrie, 2004). Ultimately, scar tissue forms which leads to blindness (Gurthrie and Guthrie, 2004).
Health Promotion and Education
It is vital to implement a programme of education to support G in developing not only the skills to properly monitor her condition but also to motivate her to accept and engage with her disease. There is evidence from clinical trials that lifestyle modifications and effective health education contributes to a reduction in the risk of diabetic comllications (Anthony et al, 2004). Skinner et al (2003) draw attention to the differences between programmes which are based on ensuring patient compliance with healthcare professional-designed management, and programmes which focus on a client-centred approach. A client-centred approach might be the more appropriate in this instance given G’s previous non-compliance with insulin and diet regimes. The literature on diabetes unequivocally demonstrated that diabetic clients must understand their disease and be empowered to avoid unhealthy behaviour ssuch as smoking and unhealthy diets, and be encouraged to exercise and control blood glucose (Anthony et al, 2004). G’s lifestyle appears healthy in terms of exercise, but it is glycaemic control which must be addressed here.
It is also vital to employ a multi-disciplinary approach with collaborative care co-ordinated by diabetic specialists – both medical and nursing (NSF). It has been found that seamless care of the diabetic client can result in a shortened length of stay in hospital, and can help prevent recurrent admissions due to poor self-management (Pollom and Pollom, 2004). Research continues to demonstrate that such services are still falling short of the published standards (Edge et al, 2005). Keen (2005) argues that there is still a need for an integrated approach to diabetes with close collaboration and sharing between primary and secondary care providers. There should be networks of diabetes specialists traversing the boundaries of acute and community sectors, for example, to support an ongoing integrated service that allows client needs to be met appropriately (Keen, 2005). However, having a lead professional (ie nurse) who coordinates such a programme is also important (Scott, 2006).
Dietician involvement is vital in this instance, as both an immediate form of intervention and in the promotion of long-term optimisation of health (Pollom and Pollom, 2004). It is also important to involve community services at this stage, as it has been demonstrated in the literature that community support programmes are effective in promoting healthy lifestyles for diabetic clients (Robinson, 2006). Watkins (2003) states that much great finesse is needed in design of diabetic diets, because if they eat too much, diabetic control deteriorates, and if they eat too little, they become hypoglycaemic. The important principle is that carbohydrate intake should be steady from day to day (Watkins, 2003).
In terms of health education, G needs to be re-educated in calibration and monitoring of her glucose testing equipment, reinforcing the importance of good glycaemic control (Reinauer, 2002). This needs to be assessed by a healthcare professional (Reinauer, 2002). G also needs to be reminded that the strips need to be stored in an airtight container and kept upright (Reinauer, 2002). However, it is also vitally important to address the psycho-social aspects of G’s condition or the behaviours or emotional response which may be affecting her engagement with the management of her condition (Watkins, 2003). Emotional, social and psychiatric disorders can underlie disruptive diabetes (Watkins, 2003). Ongoing social and psychiatric support may be appropriate in this instance. This kind of support may be particularly important in supporting G to prevent the inevitable long-term health problems caused by poor glycaemic control.
Diabetes UK, the leading UK charity for people with diabetes, recommends the implementation of a structured education programme (Diabetes UK, 2006). Taking into account the emotional, social and lifestyle implications, such programmes aim to empower people with diabetes to achieve true self-management (Diabetes UK, 2006; NICE, 2003). The programmes need to have a curriculum, be implemented by trained educators, and be audited (Diabetes UK, 2006). They need to be locally accessible, ongoing and suited to the needs of the individual, either in group formats or on a 1-1 basis (Diabetes UK, 2006; NICE, 2003: Skinner et al, 2003). Whether or not G will have access to such a programme remains a postcode lottery, despite the recommendations of the NICE guidelines (NICE, 2003; DH, 2002; Diabetes UK, 2006). Therefore a realistic assessment of available continuing care facilities for G is vital for her future health and wellbeing. It may also help in keeping her motivated and compliant (Funnell, 2004). Diabetes UK (2006) assert that ‘structured education can help people to engage more effectively with their healthcare professional and this, in turn, enables them to make better informed choices about their individual healthcare.’ Telephone or video-link support may also be of some benefit (Bowles and Dansky, 2003).
As can be seen from this case, presentation of Type 1 Diabetes in the young adult can be a challenge for the client and for those charged with treating and supporting them. G’s case demonstrates the need for acute and ongoing healthcare services to work collaboratively and consistently, providing continuity of support that is locally based and tailored to meet individual needs. This support could be vital to minimise the long-term complications of diabetes, improving individual quality of life and reducing the future demands on the already over-stretched UK health service.