Practice tips

• For every diagnosed diabetic there is an undiagnosed diabetic; so vigilance for diagnosing diabetes is important.

• Follow-up programs should keep to a prepared format. A format that can be used for IDDM is presented in Table 17.5 . This can be modified for NIDDM.

• Hyperglycaemia is a common cause of tiredness. If elderly type II diabetic patients are very tired, think of hyperglycaemia and consider giving insulin to improve their symptoms.

• The management of the diabetic patient is a team effort involving family members, a nurse education centre, podiatrists, domiciliary nursing service, general practitioner and consultant.

• If a diabetic patient (particularly IDDM) is very drowsy and looks sick, consider first the diagnosis of ketoacidosis.

• Foot care is vital: always examine the feet when the patient comes in for review.

• Treat associated hypertension with ACE inhibitors or a calcium channel blocker (also good in combination).

• Use a team approach and encourage joining special support groups (e.g. Diabetes Australia).

Table 17.5 Type I (IDDM): A follow-up program 5

History 1 Smoking and alcohol use . Symptoms of hypoglycaemia, hyperglycaemia Check symptoms relating to eyes, circulation, feet*

Examinations Weight, height; BMI Blood pressure—standing and lying Examine heart* 2. Carotid and peripheral pulses*

2. Eyes

• visual acuity (Snellen chart)

• optic fundi (or ophthalmologist referral)*

• ? diabetic retinal photography

Tendon reflexes and sensation for peripheral neuropathy* Skin (general)

Foot examination including footwear* Check injection sites

Urine examination: protein, ketones, glucose, nitrites

Biochemistry Blood glucose

3. Glycosylated haemoglobin . Urea and creatinine

Lipids

Urine microalbumin* (overnight collections)

4. Education on self-management

. Diet—or dietary review by dietician

Self-monitoring of blood glucose. Check patterns of use of blood glucose test strips and examine test profiles.

Exercise program

5. Review insulin regimen and dose

6. Consider other specialist referrals

7. Schedule review appointment—forgetting to do this is a frequent cause of failure to return.

Items marked * comprise a program for detection of long-term complications. They should be conducted annually, commencing 5 years after diagnosis.

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