Care of the Patient with Diabetes

Diabetes is an endocrine disorder "characterized by high levels of blood glucose with a defect in insulin secretion or action" due to defects in the metabolism of carbohydrates, fats, and protein (Cash & Glass, 2019, p. 733). Chronically elevated blood glucose levels directly impact the body's nerves, blood vessels, and muscles, putting a person at risk for serious complications. To better understand diabetes, it is important to understand how the endocrine system works.

The endocrine system is made up of glands that secrete hormones necessary for the proper function of the body's systems. The pancreas, which is a part of the endocrine system, is the organ directly involved in the pathophysiology of diabetes. The pancreas has two main types of cells: the acinar and the islets of Langerhans. The islet is composed of beta cells, which secrete the hormone insulin. After a person eats, the pancreas responds to the increase in blood glucose by releasing insulin. Insulin is used by the body to move glucose, or sugar, into cells. If the pancreas cannot produce enough insulin or the body cannot use insulin properly, glucose builds up in the bloodstream. It is the only hormone that has a direct effect on lowering glucose levels (Cash & Glass, 2019).

So now we know that insulin is produced by the pancreas in response to the release of glucose into the bloodstream after eating. But how does insulin control blood glucose levels? Insulin distributes glucose into the cells of the liver as well as in skeletal muscle cells and fat cells or adipocytes. The liver cells play a key role in storing the glucose and converting it to glycogen, which is released when the body needs the blood glucose to increase. If the glucose is not properly transported to those targeted cells, blood glucose levels remain elevated. In summary, when the endocrine system is functioning as it should, then insulin will lower the blood sugar levels when needed, and glycogen will increase the blood sugar levels when needed. This delicate balance prevents the breakdown of protein, which will be used as a source of fuel if there is not enough glycogen to be used as energy (Cash & Glass, 2019).

Diabetes can be categorized into four different types, all of which have slightly different etiologies. Categories include type I diabetes, type II diabetes, gestational diabetes, and diabetes secondary to genetic defects, medications, chemicals, or disease(s) (Cash & Glass, 2019).

Type 1: Type I diabetes, formerly known as insulin-dependent diabetes, is characterized by severe insulin deficiency due to the destruction of the pancreas' insulin-producing beta cells (Dunphy et al., 2019). 90% of cases of type I diabetes are the result of an autoimmune response, and the other 10% are idiopathic. Although type I diabetes is most common in children less than 18 years of age, it can occur in adults. It is believed type I diabetes is triggered by a viral infection or toxic overload in persons with a genetic predisposition. These patients are rarely presented as obese and are more likely to suffer from other autoimmune conditions, including Graves' disease, Hashimoto's, Addison's disease, and pernicious anemia (Dunphy et al., 2019). Type I diabetics require lifelong insulin and close monitoring. These patients are at an increased risk of severe complications such as diabetic ketoacidosis (Lucier & Mathias, 2024).

Type II: Type II diabetes, formerly known as non-insulin-dependent diabetes, is the most commonly occurring form of diabetes and is most often seen in patients older than 45 years (Goyal et al., 2023). There are two important deficits that occur in the body, resulting in type II diabetes. The first issue is there is not enough insulin secretion by the pancreas. Secondly, the tissues that are most sensitive to insulin become less sensitive or desensitized and do not respond how they should. This change in insulin sensitivity is defined as insulin resistance (Galicia-Garcia et al., 2020). Important risk factors include a sedentary lifestyle, excessive sugar and ultra-processed food intake, and family history (Cash & Glass, 2019).

Gestational diabetes: Gestational diabetes is the third type of diabetes and strictly occurs during pregnancy, usually by the second or third trimester. The American Diabetic Association (ADA) defines gestational diabetes as ongoing glucose intolerance and insulin resistance (Sharma et al., 2022). Due to complex metabolic shifts during pregnancy, some women do not produce enough insulin to keep up with the demand for glucose in the bloodstream. Fortunately, most cases of gestational diabetes resolve after giving birth. The most common risk factors include rapid weight gain, obesity, sedentary lifestyle, family history, and advanced gestational age (Sharma et al., 2022).

Secondary diabetes: Lastly, there is secondary diabetes that develops from diseases such as pancreatitis, endocrine disorders like Cushing's disease, or long-term use of certain drugs such as corticosteroids (Goyal et al., 2023). It is more common to see this type of diabetes in the elderly population due to polypharmacy and comorbidities.

Despite varying pathophysiology, there are many shared signs and symptoms between the four types of diabetes. It is important to note that each individual case of diabetes can present differently. These are the signs and symptoms to be aware of when caring for a patient: fluctuating glucose levels, lack of energy and fatigue, delayed wound healing, and increased risk for infections. Patients typically experience the 3 P's: polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). As the disease progresses, patients may complain of numbness and tingling in their hands and/or feet, blurred vision, and poor circulation in their extremities. Patients with type I diabetes tend to lose weight unintentionally, whereas gestational and type II diabetics tend to gain weight or be overweight or obese initially (Goyal et al., 2023).

Diabetes is controlled through diet and exercise modifications as well as oral glucose-lowering medications and insulin. For the best outcomes, a patient with diabetes should be cared for by an interdisciplinary team that includes a primary care provider, dietician, endocrinologist, and diabetic educator. For a patient's diabetes to be considered controlled, the patient must achieve steady blood glucose levels most of the time. Ideal levels would be between 80-130 milligrams (mg)/deciliter (dL) before meals and less than 180 mg/dL 1-2 hours after a meal. For patients with type I diabetes, this is typically achieved with insulin injections or an insulin pump. For people with type II diabetes or gestational diabetes, oral glucose-lowering medications are first-line (Dunphy et al., 2019). Sometimes, a combination of the two categories of medicine is required. The importance of lifestyle modifications cannot be underscored enough. It is worth noting that in up to 85% of gestational diabetes cases, diabetes can be managed with adequate exercise and dietary changes (Nakshine & Jogdand, 2023). According to the ADA, the Mediterranean diet and vegetarian or vegan meal patterns are research-backed meal plans that can help maintain steady blood glucose levels (ADA, n.d.).

If diabetes is not well managed, there are a variety of complications that can occur, including diabetic ketoacidosis, hyperosmolar hyperglycemic state, kidney disease, retinopathy, hyperlipidemia, nephropathy, hypertension, and macrovascular disease. Women with gestational diabetes are at an increased risk for preterm delivery, preeclampsia, and cardiac and renal malformations (Dunphy et al., 2019).

The CNA plays a key role in the management of a patient with diabetes. It is possible that the CNA is the person the patient sees the most, which makes the CNA more likely to notice changes or unusual behaviors.

The CNA should be familiar with the patient's medications, diet, and exercise regimen. The patient may be on a special diet and may be eating foods they do not particularly like. Explain the importance of food choices to help the patient understand why they are on this diet (Dunphy et al., 2019). Maintain a record of all the food consumed along with glucose levels to track the patient's health and prevent dangerous situations. Report to the nurse any abnormalities in food intake such as skipping meals or sudden changes in appetite. Inadequate fluid intake or excessive activity should also be reported to the nurse.

Be sure to report any missed medications and ask the patient if they understand how to administer the medication properly. Additionally, know where the patient keeps carbohydrates such as orange juice, Karo syrup, or crackers in case of an emergency (Dunphy et al., 2019).

Due to the increased risk of slow-healing wounds and infection, it is important to monitor cuts, sores, or persistent bruising. The feet and lower extremities are often at greatest risk for injury, especially if the patient suffers from diabetic neuropathy. Ensure the skin is clean and dry, and encourage the patient to wear nonslip socks or house shoes to prevent injury. If a wound develops or a known wound shows signs of infection, such as redness, warmth, foul odor, pus, swelling, or increased pain, report these findings to the nurse or healthcare provider promptly (Dunphy et al., 2019).

Check the patient's oral hygiene and cleanliness. Make sure they are bathing regularly to prevent skin infection. Assist the patient with tooth brushing and flossing. Report any signs of infection or foul odor to the nurse. Also, any unusual, sweet odor on the breath should be reported as well, as this could be an indication of diabetic ketoacidosis (Dunphy et al., 2019).

The CNA should be able to recognize and respond to dangerous situations such as hypoglycemia or hyperglycemia. Symptoms such as pale, moist skin, shallow and rapid breathing, irritability, or nervousness should be reported to the nurse/healthcare provider immediately. To prevent hypoglycemia, make sure the patient eats and exercises at the same time each day, has snacks between meals, and checks their blood sugar regularly throughout the day (Dunphy et al., 2019). To prevent hyperglycemia, observe for signs of illness, infection, or stress. In addition, review the patient's food intake and medication regimen. Report signs such as nausea, vomiting, diarrhea, dizziness, shakiness, racing heart, or blood sugars outside of the normal range (Dunphy et al., 2019).

Observing the patient's health, exercise, and food intake routines is an important part of care. Be sure to report any unusual signs or symptoms as well as any wounds. Monitor and report the patient's glucose levels and medication administration. Caring for the patient with diabetes also means being empathetic and supportive as their lifestyle must change to prevent complications and control the disease. Listening to the patient's concerns and helping them understand how to care for themselves is important in maintaining a productive life.

Mary is a 68-year-old woman newly diagnosed with type II diabetes. She lives at home with her husband. Mary is overweight and has high blood pressure. She and her husband are very concerned about her health. Mary was given information at her primary care provider's office about diabetes and how to control it. However, Mary and her husband tell you that they are not sure they understand the information, particularly what food Mary can eat and how to lose weight safely.

What do you do?

Mary first needs to check with her primary care provider to see what exercises she can do safely with her diagnosis of high blood pressure. Exercise should be done regularly and at the same time each day. You can also review the ADA website with Mary and her husband which has several lists of foods that can be used in meals and as snacks. Review with Mary and her husband that meals and snacks should be eaten at the same time each day. If Mary needs to check her blood glucose levels, be sure to review the procedure with her. Also, make sure Mary's medications are reviewed, ensuring she and her husband understand when and how much of the medication to take. You can also review the signs and symptoms of hypoglycemia and hyperglycemia, making sure they know when to call the primary care provider.

Jacob is a 20-year-old male who is seen for a regular check-up in the office. He is concerned about developing diabetes as his mother and sister are both diabetics. Jacob is not overweight, but he tells you that he tends to eat fast food and does not exercise. He also states that, with his school schedule, he really does not have the time to exercise, but he is open to suggestions. What do you tell Jacob?

What do you do?

Discuss with Jacob that a risk factor for prediabetes is a family history, poor eating habits, and not getting enough exercise. Even though Jacob is not overweight, he should still eat and exercise properly. Develop some ideas with him to exercise at least the recommended 150 minutes a week. This could involve walking briskly to class. Also, help him to develop a meal plan rather than eating fast foods. He can make several snacks or quick meals to store and eat between classes. Healthy food choices are important as well as exercise.