Diabetes
Diabetes is a serious, life-long condition, affecting more than
two million Canadians. It is the leading cause of death by age,
and worldwide the prevalence of diabetes is increasing annually.
Diabetes is a disorder manifested by high blood glucose levels that
result from defective insulin secretion or insulin action or a combination
of both of these problems.
There are two major classifications of diabetes. Type 1 diabetes,
which affects 10 – 15 per cent of all people with diabetes,
is primarily a result of the inability to produce insulin due to
beta cell destruction in the pancreas. While Type 1 diabetes accounts
for fewer individuals with diabetes, it results in a disproportionately
high frequency of diabetes related complications. Type 2 diabetes,
affecting over 80% of those diagnosed with diabetes, results from
a combination of insufficient insulin production and/or resistance
of the cells of the body to the actions of insulin (CDA,
1998; 2003).
Research has shown that keeping blood glucose levels normal or
close to normal lowers the risk for development and progression
of diabetes complications.
In an article that appeared in an RNAO
Practice Page on Diabetes entitled "Diabetes: A Growing
Public Health Problem", author Lynn Baughan cites an important
study called the Diabetes Control and Complications Trial (DCCT),
which found that people with Type 1 diabetes who kept blood sugar
levels close to normal through intensive therapy lowered the risks
for:
- Retinopathy (eye disease) by up to 76%
- Nephropathy (kidney disease) by 50% and
- Neuropathy (nerve disease) by 60%.
Intensive therapy included:
- Diabetes education
- Nutritional counselling
- Frequent self blood glucose testing
- Learning how to balance blood glucose levels by adjusting insulin
doses for changes in food and exercise
- Insulin administration 3 to 4 times a day or by an insulin
infusion pump and
- Monthly follow-up appointments with the diabetes health care
team.
Diabetes Nursing Best Practice Guideline: A Context
As noted in the RNAO Best Practice Guideline, Reducing
Foot Complications for People with Diabetes, regardless of the
diabetes type, over time, failure to achieve optimal glycemic control
can cause damage to the body’s small and large blood vessels
and nerves. This damage can affect the functioning of many body
organs and interfere with wound healing. In Ontario, the adjusted
rates of lower extremity amputation are approximately 20 times higher
for people with diabetes than in persons without diabetes
The Institute for Clinical Evaluative Sciences describes
a decreasing rate for minor amputations in Ontario (amputation
at the level of the foot or below) in people with diabetes (a 29%
decline from 1995 to 1999). However, rates for minor amputations
were much higher in the diabetic population compared to the non-diabetic
population – in 1999 the odds of having a minor amputation
were 24 times greater in people with diabetes.
Major amputation rates (amputation from the ankle to the thigh)
remained relatively stable in Ontario over the same five-year interval;
however rates increased with age and were significantly higher in
those with diabetes. As with minor amputation rates, major amputation
rates were significantly higher for people with diabetes. In 1999,
the risk of major amputation was 14 times higher for those with
diabetes, even after adjusting for differences in age and sex.
Not only does diabetes seriously affect the lives of individuals
and their families, it poses a significant societal burden as well.
The Canadian Diabetes Association (2003)
indicates that although economic analyses of the cost of diabetes
to the Canadian health care system vary widely, a recent study calculated
that the economic costs of diabetes in Canada in 1998 was between
$4.76 billion and 5.23 billion (U.S.).
In light of the serious and costly impact of diabetes, lower extremity
ulceration and amputation, and the potential of nursing intervention
to positively influence this problem, reducing foot complications
for people with diabetes was selected as the focus for this nursing
best practice guideline. Nurses are in a unique position to promote
the maintenance of healthy feet, identify problems in early stages,
positively influence self-care practices, and refer high-risk individuals
for specialized care. They are in contact with individuals who have
diabetes across their life span, in a multitude of practice settings
from emergency departments, tertiary care hospitals and long-term
care facilities to physicians’ offices, community clinics,
clients’ homes, workplaces and public venues. Health promotion
and the facilitation of effective self-care through education are
essential elements of nursing practice.
The development panel of the Reducing
Foot Complications for People with Diabetes guideline acknowledges
the stressful conditions in which nurses work and in particular,
the demands on the time of nurses in various practice settings.
With this in mind, the recommendations are targeted to allow nurses
who do not specialize in diabetes education and care to conduct
a quick assessment to identify key risk factors for foot ulcers
in clients with known diabetes. This guideline recommends that all
nurses encourage and support clients who are identified as being
at increased risk for foot complications in their efforts to access
appropriate, specialized diabetes services for more in-depth assessment
and intervention.
Diabetes care and education is best provided by a specialized,
interdisciplinary team working closely with the clients and their
families to address the complex lifestyle, self-care, and multiple
treatment demands of diabetes (CDA, 1998; 2003).
It is acknowledged that this level of care is not yet accessible
to, or accessed by, all people with diabetes. Fewer than 40 per
cent of the people in Ontario who have diabetes receive formal education
about their condition and its management. Risk-reducing foot care
is one aspect of diabetes self-management that all nurses can facilitate
and positively influence in the quest to reduce foot complications
and associated traumatic sequelae in people with diabetes.
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