diabetes case study

Introduction

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).

Case History

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).

Care Needs

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).

Immediate Care

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):

Immediate Resuscitation

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).

Oxygen therapy

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.

Intravenous Access

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.

Insulin therapy

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).

Ongoing Care

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).

Monitoring

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).

Conclusion

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.