THE EIGHT PRINCIPLES OF NURSING PRACTICE

The eight Principles describe what the public can expect from nursing practice in any setting. They have been produced jointly between nurses and patient groups.

1. Nurses and nursing staff treat everyone in their care with dignity and humanity - they understand their individual needs, show compassion and sensitivity, and provide care in a way that respects all people equally.
2. Nurses and nursing staff take responsability for the care they provide and answer for their own judgements and actions - they carry out these actions in a way that is agreed with their patients, and the families and carers of their patients, and in a way that meets the requirements of their professional bodies and the law.
3. Nurses and nursing staff manage risk , are vigilant about risk, and help to keep everyone safe in the places they receive health care.
4. Nurses and nursing staff provide and promote care that puts people at the centre, involves patients, service users, their families and their carers in decisions and helps them make informed choices about their treatment and care.
5. Nurses and nursing staff are at the heart of the communication process: they assess, record and report on treatment and care, handle information sensitively and confidentially, deal with complaints effectively, and are conscientious in reporting the things they are concerned about.
6. Nurses and Nursing staff have up-to-date knowledge and skills, and use these with intelligence, insight and understanding in line with the needs of each individual in their care.
7. Nurses and nursing staff work closely with their own team and with other professionals, making sure patients´ care and treatment is co-ordinated, is of a high standard and has the best possible outcome.
8. Nurses and nursing staff lead by example, develop themselves and other staff, and influence the way care is given in a manner thet is open and responds to individual needs. 

Source: Royal College of Nursing,

http://www.rcn.org.uk/development/practice/principles

RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL (CARE PLAN GUIDE)

This is my first post regarding Care Plans in English. All  information in this blog about care plans is just a guide as they need to be individualized and rationales (which I omitted) should be included, each diagnosis developed is based on NANDA International label.

RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL (NANDA -1 diagnosis)

Definition: risk for variation of blood glucose/sugar levels from the normal range.

Common Risk Factors

-Insulin deficiency or insulin excess.

-Excessive glucose intake in relation to metabolic needs.

-Medication side effects.

-Imbalance of activity and food intake.

Common Expected Outcome

-Patient maintains blood glucose levels within defined target ranges.

Source: Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.

EMERGENCY TREATMENT FOR DIABETES

If not treated quickly enough, fluctuations in blood glucose levels can lead to a person with diabetes becoming unwell and losing consciousness. The two conditions associated with diabetes are:

• hyperglycaemia - high blood glucose
• hypoglycaemia - low blood glucose.

The more common emergency is hypoglycaemia which affects brain function and can lead to unconsciousness if untreated.

Diabetic ketoacidosis (DKA) is a life threatening complication in patients with untreated diabetes or improperly managed diabetes. It is most common among type 1, but it can also occur in type 2 if the body becomes physiologically stressed, for example during an infection.  

Signs and symptoms of hypoglycaemia and hyperglycaemia in type 1 diabetes

• Hypoglycaemia (low blood sugar)

Hypoglycaemia occurs when any insulin in the body has moved too much glucose out of the bloodstream and blood glucose levels have become very low. This is usually because the patient has taken too much insulin, exercised too vigorously or consumed alcohol on an empty stomach. This is commonly called a 'hypo'. Usually hypoglycaemia can be corrected simply by eating or drinking something with a high glucose content. If hypoglycaemia is not corrected, it can progress to more advanced symptoms such as slurred speech, confusion and ultimately unconsciousness. If a person loses consciousness they will need to have an emergency injection of a hormone called glucagon to raise the level of glucose in their blood.

Some people with diabetes are at particular risk of hypoglycaemia:

-those who frequently experience hypoglycaemia, even if they are able to treat themselves

-people who have poor awareness of hypoglycaemia symptoms

-people who fast (e.g. during Ramadan)

-those who vary their eating or exercise patterns

-older people, particularly those in the early stages of dementia

-people with poor mental health

-people with a learning disability

-people with alcohol-related health problems

-people with poor injection technique

-people not using glucose lowering therapies correctly (e.g. dose or timing)

-women who are pregnant or breastfeeding.

Hypoglycaemia has potentially severe consequences for some groups of people e.g. those who drive, work at heights, or live alone.

• Hyperglycaemia (high blood glucose)

Hyperglycaemia occurs when the body cannot produce any, or enough, insulin to regulate blood glucose. Consequently blood glucose levels become too high. This happens when there is no insulin to move glucose out of the bloodstream and into the cells to produce energy. The symptoms of hyperglycaemia are similar to the main symptoms of diabetes but they can come on suddenly and severely. If left untreated, hyperglycaemia can lead to diabetic ketoacidosis (DKA), which can eventually cause unconsciousness and even death. Hyperglycaemia can occur for several reasons including:

-eating too much

-being unwell

-steroid use e.g prednisolone.

Signs and symptoms of hypoglycaemia and hyperglycaemia in type 2 diabetes

• Hypoglycaemia (low blood glucose)

People with type 2 diabetes who manage the condition with a combination of healthy eating and physical activity are not usually at risk of hypoglycaemia. If people are not taking any medications to lower their blood glucose levels, they don't tend to drop too low to cause a 'hypo' episode. Severe hypoglycemia is also very rare among people with type 2 diabetes who are taking blood glucose lowering medications such as metformin (Glucophage).

However people with type 2 diabetes who take medications that increase the amount of insulin released from the pancreas can be at risk of low blood glucose levels. These medications include Gliclazide, Glipizide and Glimpiride. Hypoglycemia also can happen in people with type 2 diabetes who use insulin.

• Hyperglycaemia (high blood glucose)

Type 2 diabetes develops because the body either can not produce enough insulin or because the cells in the body do not respond properly to insulin. Consequently, blood glucose levels become too high. This happens when there is no insulin available to move glucose out of the bloodstream and into the cells to produce energy. As with type 1 diabetes, the symptoms of hyperglycaemia are similar to the main symptoms of diabetes but can come on suddenly and severely and for the same reasons as stated with type 1 diabetes.

If left untreated, hyperglycaemia untreated can lead to a hyperosmolar, hyperglyceamic state. People with type 2 diabetes are extremely unlikely to develop diabetic ketoacidosis (DKA) and are more likely to develop Hyperosmolar Hyperglycaemic State or HHS. Like DKA, this condition is also life threatening with a high mortality rate.

The initial treatment will depend on the person's level of conciousness and their ability to self treat. 

Diabetic ketoacidosis (DKA)

DKA is a life threatening complication in people with untreated diabetes or improperly/difficult to managed diabetes. It is most common in type 1 diabetes but it can also occur in type 2. The difference between hyperglycaemia and DKA relates to the level of ketones and dehydration.

Frequently people with undiagnosed type 1 diabetes present to hospitals with DKA. DKA can also occur in people with diabetes who have an overwhelming infection or in people who have misadministered their insulin doses. Before insulin injections became available, DKA was a major cause of death in patients with type 1 diabetes. DKA mimics the signs and symptoms of newly diagnosed type 1 diabetes and if not corrected, DKA progresses to more advanced symptoms of laboured breathing (Kussmaul respiration), coma and eventually, death.

The signs and symptoms of DKA include:

• feeling sluggish progressing to extreme tiredness
• fruity smell to breath (similar to the smell of nail polish remover)
• extreme thirst, despite large fluid intake
• constant urination (may include bedwetting)
• extreme weight loss
• oral thrush or yeast infections that won't resolve
• muscle wasting
• vomiting - this is a late sign and at this point, 

DKA is life threatening and medical attention should be sought immediately, particularly if they are unable to keep fluids down. DKA in pregnancy and children can be lethal so requires an emergency hospital admission.

Source: RCN

DIABETES

Diabetes is a common condition affecting all aspects of an individual’s life. Associated complications can be costly and have a significant affect on the person's quality of life. With the help and support of nursing staff the condition can be managed. Self-management skills are an essential part of diabetes care for every patient.

Diabetes is a common long-term health condition caused by too much glucose, a type of sugar, in the blood. It is also known as diabetes mellitus. 

Diabetes is a condition where the amount of glucose in a person’s blood is too high because their body is unable to process the glucose properly. This could be for two reasons:

• the pancreas doesn’t produce any insulin, or not enough, to help glucose enter the cells of the body
• the insulin that is produced does not work properly – this is known as insulin resistance.

Insulin is the hormone produced by the pancreas that allows glucose to enter the body’s cells. Here the glucose is used as fuel, providing the body with energy for body function, movement and everyday living. Insulin is vital for life.

If a person has diabetes, their body cannot make proper use of glucose. The glucose builds up in their blood and they are unable to produce the energy needed for everyday life.

Types of diabetes

Type 1 diabetes

Type 1 diabetes develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce insulin. No one knows why this happens but the most likely reason is that the body has an abnormal reaction to the cells. This could be triggered by an infection or virus but again this is not known for sure. Type 1 diabetes is often referred to as insulin-dependent diabetes. It can develop at any age but usually appears before the age of 40, and especially in childhood. A person with type 1 diabetes will need to take insulin injections for life. They will also need to ensure that their blood glucose level stays balanced by eating a healthy diet and carrying out regular blood tests. People with type 1 diabetes make up only 10% of all people with diabetes. 

Type 2 diabetes

Type 2 diabetes develops when the body can still produce some insulin but not enough for it to function properly, or when the cells in the body do not react properly to insulin. This is called insulin resistance. The treatment of type 2 diabetes centres on lifestyle management including a healthy diet, regular exercise and the person monitoring their blood glucose level. As the condition progesses over time oral glucose therapies are also used, with or without additional insulin injections. There are several oral therapies for diabetes. Some help the body to use insulin more effectively whilst others increase the amount of insulin that the body produces.

Type 2 diabetes is often associated with obesity. Obesity-related diabetes is sometimes referred to as maturity-onset diabetes because it is more common in older people. However, it is also increasingly becoming more common in children, adolescents and young people of all ethnicities. 

Diagnosis of diabetes

Type 1 diabetes symptoms normally develop very rapidly, sometimes over a couple of weeks. They tend to be more severe. Type 2 diabetes symptoms are normally milder and develop slower. These symptoms are caused by the effect of diabetes on the body.

If the level of glucose in the blood becomes too high, excess glucose is removed from the blood by the kidneys and excreted via the urine (glycosuria). This results in greater urine production and causes the patient to urinate frequently. Water held in the cells is required to replace lost blood volume, and thus causes dehydration and thirst.

What are the main symptoms for type 1 diabetes?

There are the major indicators of diabetes:

• polyuria - the need to urinate frequently
• polydipsia - increased thirst & fluid intake
• polyphagia - increased appetite
• weight loss
• tiredness.

Symptoms of type 1 diabetes can develop quickly, over weeks or even days.

What are the other major signs of diabetes?

• Blurred vision - A change in glucose absorption can bring about a change in the shape of the lens in the eye, leading to an altered vision quality. This can cause blurred vision, a common complaint that can indicate type 1 or type 2 diabetes.

• Diabetic ketoacidosis - Diabetic ketoacidosis occurs when the body begins to break down stores of fat as an alternative source of energy, leading to a build-up of acids in the blood known as ketones. This can result in weight loss and muscle wasting. Diabetic ketoacidosis is a very rare complication of diabetes. Ketoacidosis can result in coma and possibly death if left untreated.

Other symptoms are:

• itchiness around the vagina or penis or getting thrush regularly
• cramps
• constipation
• skin infections

What are the main symptoms for type 2 diabetes?

In type 2 diabetes the signs and symptoms are not always obvious as the condition develops slowly over a period of years. It may only be picked up in a routine medical check up. The common symptoms are:

• tiredness
• poor healing process
• malaise
• sometimes weight gain.

Thirst and polyuria will develop as hyperglycaemia progresses, particularly in the elderly. It is important to be vigilant for the signs and symptoms of diabetes as early diagnosis and treatment can reduce the risk of developing complications later. Many people have type 2 diabetes for years without knowing it because early symptoms can be general.

Tests to diagnose diabetes and pre-diabetes.

HbA1c Blood test.

HbA1c will become the most common method of diagnosing diabetes, as recommended by WHO. This test measures recent average blood glucose level. The test measures a part of the red blood cells. Glucose in the blood attaches to part of the red blood cells. This part can be measured and gives a good indication of an average blood glucose over the previous 2-3 months. A blood sample is required. An HbA1c of 48mmol/l (6.5%) or more is a diagnostic of diabetes in most situations. HbA1c is also used to monitor diabetes in a patient and will normally be done every 2-6 months. Patients with diabetes aim to lower the HbA1c level to below a target level normally around 6.5% - 7.5%. However, the target level is set by the diabetes team, as the levels may vary for each patient.

When it cannot be used:

• children and young people
• if patient is suspected of having type 1 diabetes
• patients has symptoms of diabetes for less than two months
• patients who are acutely ill
• if patient is taking medication that may cause rapid glucose rise, for example steroids
• patient has acute pancreatic damage, including pancreatic surgery.
• pregnancy
• patients with abnormal red blood cells such as Thalissaemia.

Random blood glucose test

In a medical emergency, when a patient (most often a child) has such high glucose levels that they are drifting in and out of a coma, a blood glucose reading can be taken by taking a blood sample to measure the glucose with no consideration to when the last meal was eaten. A level of 11.1 mmol/L or more in the blood sample indicates diabetes. A further blood glucose test will need to be done to confirm the diagnosis.

Fasting blood glucose test (FBG)

The FBG test is taken using a blood sample obtained following a period of fasting (so no food or drink, except water) of at least eight hours. The fast normally starts from midnight. A sample of blood is taken early the next day, before food or drink. A level of 7.0 mmol/L or more after an overnight fast indicates diabetes. To confirm the diagnosis, it is usually necessary to repeat the test a second time on a different day.

Oral glucose tolerance test (OGTT)

For this test the patient fasts from midnight and then a baseline fasting blood glucose test is taken. The patient then consumes a drink which contains 75g of glucose (lucozade is normally used) and then they wait for 2 hours before their blood glucose is measured again. This test is different from the others as the patient drinks a sugary drink as a way of measuring how the pancreas manages the glucose. In a person without diabetes glucose levels rise and fall quickly, as the body naturally produces insulin to lower the blood glucose. A person with diabetes will see a sharp rise and a sustained high level of glucose. This is because the pancreas is unable to deliver the needed insulin to lower the glucose in the blood. A blood glucose level of 11.1 mmol/L or more in the blood sample taken after two hours indicates diabetes.

Urine test for glucose

A simple dipstick test can detect glucose in a sample of urine. In a dipstick test a doctor or nurse uses a special chemical strip which is dipped into a sample of the patient's urine. Colour changes on the strip show whether there is glucose in the urine sample. Some people have kidneys that are more 'leaky', and glucose may leak into urine with a normal blood level. If a patient's urine contains any glucose a blood test should be carried out to measure the blood level of glucose to confirm, or rule out, diabetes.

Whether a fasting glucose, random glucose or HbA1c is used to test for diabetes it will generally need repeating as there should be evidence of 2 results using the same testing method to confirm diagnosis test.

Treatment of diabetes

Diabetes cannot be cured, but it can be managed. Treatment aims to:

• keep blood glucose levels as near normal as possible
• reduce any other risk factors that may present and increase the risk of the patient developing complications - particularly to keep blood lipids (cholesterol) low and to lower blood pressure if it is high
• detect any complications as early as possible. Early diagnosis and treatment can prevent or delay some complications from getting worse.

The type of treatment that a patient will require will also depend on the type of diabetes that they have. Treatment falls in to the two broad categories of lifestyle and medication.

Lifestyle

A patient diagnosed with diabetes will need to take additional care of their health. They will need on-going advice and support about maintaining a healthy diet, keeping active and monitoring their health. Diabetes does not have to be a burden, people can live normal active and healthy lives and very small adjustments to their lifestyle can make signifcant improvements. Most diabetes management relies on a person 'self managing' the condition so their motivation is a major key to effective treatment.

People diagnosed with pre-diabetes can slow down or prevent the condition from developing into type 2 diabetes by making lifestyle changes as well. The following are significant factors in the management of diabetes and should be discussed with each person:

• healthy eating
• keeping active
• weight management
• smoking cessation and alcohol consumption
• emotional wellbeing.

Medication

Treatment for diabetes aims to help people with the condition to control their blood glucose levels and minimise the risk of developing complications over time.

Treatment for type 1 diabetes

Lack of insulin production by the pancreas makes type 1 diabetes particularly difficult to control. A management plan defined by the diabetes team that centres around the needs and goals of a person typically includes dietary advice and maintaining a constant health weight, home blood glucose monitoring and exercising regularly. Unfortunately, the treatment cannot eliminate the need for insulin or reverse the disease.

There is also a sub-type of type 1 diabetes known as 'brittle diabetes' (or 'labile diabetes'). This type of diabetes is particularly hard to control. People who have brittle diabetes will experience frequent, extreme swings in blood glucose levels, causing episodes of hyperglycaemia or hypoglycaemia. These fluctuations are more serious and tend to result in frequent hospital visits, interruption to employment and can often contribute to psychological issues such as stress.

Insulin

All patients with type 1 diabetes will need to have daily insulin injections as their body is unable to produce any insulin. The injections come in the form of a syringe, insulin pen or insulin pump. The reason that insulin is injected is because if it were taken as a tablet, it would be broken down in the stomach and would not enter the blood stream. When a person is first diagnosed, the diabetes team will teach them the correct procedure for their injections. This involves showing them when, where and how to inject themselves and how to adjust insulin doses. They will explain how to store the insulin and safely dispose of the needles.

Each person who is taking insulin has to carry an 'Insulin Passport' or 'Insulin Safety Card'.

Treatment for type 2 diabetes

It is possible for a person to initially control the symptoms of type 2 diabetes by following a healthy diet, taking regular exercise and keeping their blood glucose levels within an agreed target range. Type 2 diabetes is a progressive condition so they may eventually need to take diabetes medication which will usually be in tablet form. A treatment programme will be tailored to suit the person's needs by the diabetes team and will typically include one or a combination of the following:

• changing to a healthier diet
• medication such as Metformin
• insulin therapies.

Keeping blood glucose levels under control is vital in reducing the risk of diabetes complications. If a person is overweight, weight loss can often help to reduce the extent of diabetes symptoms. Type 2 diabetes is effectively controlled when a person is involved in the management of their own programme of treatment. Effective 'self management' is essential to successfully achieving their healthy targets for HbA1c, blood pressure and cholesterol levels. A person with type 2 diabetes may need (or eventually need) medicatiion that reduces high levels of blood glucose. In the first instance this will usually be glucose-lowering tablets (sometimes a combination of more than one type of tablet) and it may also include injectable insulin. Some oral medications for lowering blood glucose levels can cause hypoglycaemia for example, Gliclazide, Glipizide and Glimpiride.

Source: RCN