Diabetes Manual_ a Guide to Diabetes Management.pdf

DIABETES
MANUAL
A guide to diabetes management
Published by Diabetes Outreach
© Diabetes Outreach 2009
7th Edition

Published by Diabetes Outreach
8 Woodville Road
WOODVILLE SA 5011
Phone: (08) 8222 6775
Fax: (08) 8222 6768
Diabetes Manual: A guide to diabetes management
7th
Ed. September 2009
ISBN: 978-0-9756985-7-0
1. Diabetes – Handbooks, manuals, etc
616.462

Acknowledgements
EDITORIAL TEAM – 7th
Edition 2009
Melissa Carapetis Dietitian, Diabetes Centre,
The Queen Elizabeth Hospital
Martin Dowell Diabetes Educator RN CDE
Salisbury Primary Health Care
Hilary Durrant Specialist Pharmacist,
Helen Edwards Diabetes Counsellor,
Diabetes Counselling Online
Shelley Farrent Dietitian, Diabetes Education Unit,
Flinders Medical Centre
Jane Giles Manager – Education RN CDE,
Diabetes Outreach
Lyn Green Clinical Services Coordinator, Diabetes Centre,
Royal Adelaide Hospital
Dr. Mitra Guha Director, Diabetes Services,
Royal Adelaide Hospital
Mary Hodgson Diabetes Educator RN CDE, Diabetes Centre,
Collette Hooper Clinical Services Coordinator, Diabetes Education Unit,
Dr. Bill Jefferies Director, Department of Medicine,
Lyell McEwin Hospital
Sara Jones Senior Lecturer Podiatry,
University of South Australia
Mirella Kakogianis Dietitian, Diabetes Education Unit,
Jill Lyon-Green Clinical Services Coordinator RN CDE, Diabetes Service,
Lyell McEwin Hospital
Sally Marotti Specialist Clinical Pharmacist,
The Queen Elizabeth Hospital.
Sue McCullough Diabetes Educator RN CDE, Diabetes Education Unit,
Repatriation General Hospital
Kaye Neylon Project Consultant, RN CDE
Diabetes Outreach
Dr Pat Phillips Senior Director, Endocrinology,
Diana SonnackClinical Nurse Consultant RN CDE,
Royal District Nursing Service
Connie Stanton Dietitian, Diabetes Centre,
Kate Visentin Clinical Nurse – Education CDE,
Diabetes Outreach

FOREWORD
Welcome to the seventh edition of the Diabetes Manual. We are pleased to
acknowledge that the Diabetes Manual continues to be a consistent and evidence
based resource for rural and remote health services in country South Australia it is also
recognised and utilised by many metropolitan health services.
Diabetes is and continues to be a significant and rapidly growing global public health
issue and in fact could be viewed as a disease in the numbers akin to an epidemic.
Type 2 diabetes affects over 6% of the Australian adult population and makes up about
85 – 90 % of all diabetes. Type 1 diabetes makes up about 10 – 15 % of all diabetes
and is increasing at a rate of approximately 3% per year. Gestational diabetes affects
4.9 % of all pregnancies and is a significant risk factor for the development of type 2
diabetes later in life.
In Australia, diabetes is the second most common reason for renal dialysis, the most
common cause of blindness in people over the age of 60 years, the most common
cause of non-traumatic amputation and one of the more common chronic diseases
amongst children.
Developed in consultation with a team of very experienced and committed health
professionals, the manual’s main objective is to provide users with information on the
latest trends and guidelines on the management of the education and information. The
Editorial Team welcome and invite any user of this manual to submit their ideas on
further improvements for future editions.
I commend this manual to you the user and trust that you will find it informative and
useful and encourage you to introduce other health professionals to it to assist them in
managing their clients and patients. This manual is a very valuable resource tool in the
management and continuing education for individuals with diabetes.
The Editorial Team 2009

CONTENTS
Section 1 Introduction
Section 2 Understanding diabetes
Section 3 Diabetes education
Section 4 Hospitalisation
Section 5 Monitoring diabetes control
Section 6 Footcare
Section 7 Community groups with specific needs
Section 8 Healthy eating and diabetes
Section 9 Maintaining a healthy lifestyle
Section 10 Medication
Section 11 Unstable diabetes
Section 12 Long term complications
Section 13 Pregnancy and diabetes
Section 14 Residential care
Section 15 Resources
Section 16 Reference

SECTION 1 – INTRODUCTION – REVISED SEPTEMBER 2009
1
SECTION 1
Introduction
Preface
This manual has been developed by a team of health professionals working in the area
of diabetes care.
‘Diabetes – Your Hospital Manual’ was originally an initiative of the staff of The Queen
Elizabeth Hospital Diabetes Centre. The original publication in 1990 was aimed at
documenting in-house hospital policies to assist staff in developing comprehensive and
effective care for people with diabetes during hospitalisation.
Since that time the Manual has been updated to incorporate nationally accepted
guidelines. Diabetes Outreach aims to disseminate this information for use in a range
of hospitals and health care settings particularly in rural and remote areas. The
information contained in this manual should be used in conjunction with current local
policies and protocols.
Users of the manual are welcome to submit any suggestions for its improvement to
Diabetes Outreach.
Should you have any queries about the contents of this manual contact:
Diabetes Outreach
8 Woodville Road,
WOODVILLE SA 5011
Telephone: (08) 8222 6775
Facsimile: (08) 8222 6768

2
Purpose
This manual is designed as a reference for nurses and allied health providers working
in hospital and community settings but can be used by all health care providers who
are working with people with diabetes.
The manual aims to:
1. provide current, accurate information on the management and education of
people with diabetes
2. guide health professionals in the treatment and care of specific problems
associated with diabetes.
An improvement in the quality of diabetes health care and education provided by health
care providers is the desired outcome.
A reference list is provided at the end of each section and a glossary is included at the
end of the manual. Users of the manual are free to photocopy any relevant information
that will assist them in caring for people with diabetes.
The manual is also available online and can be downloaded free of charge at
www.diabetesoutreach.org.au.
Use of this manual
The following steps may be helpful in using this manual:
! be clear about the problem / situation
! select and read the relevant section / s
! look at recommended action / guidelines
! do what is suggested
! evaluate the outcome.
Example:
A person with newly diagnosed diabetes mellitus is in hospital for minor surgery.
! Find the problem / situation - the person has no knowledge of what diabetes is
and needs a basic introduction of diabetes while in hospital.
! Select the right sections - Diabetes education – Section 3
Hospitalisation – Section 4
! Look at recommended action / guidelines together with the individual’s needs,
ability and comprehension.
! Do what is suggested
! Evaluate outcome - has the person a simple understanding of what diabetes is?
Are there any areas that need explaining? (Evaluation may lead to identification
of a new situation / problem which requires further action).

3
Primary health care
Traditionally health care was assessed through measuring, this meant counting
numbers of bed days, numbers of people and numbers of procedures. Its success was
measured by the number of people who came in and out and how much it cost to get
them in and out. Often this did not show whether the overall health of the community
was improved. Today primary health care is concerned with the broader picture of
improving the health of the community in all the complexity that this involves.
The starting point for a primary health care approach is to provide a complete system
of care to address the community’s main health problems – that is, those which are the
most common and which have the most significant impact on the health status of the
community.1
The World Health Organisation defines primary health care as having the following
broad ideals:
! it is the first level of contact for individuals and communities with the health
system
! is located as close as possible to where people live and work
! is universally accessible - no barrier of cost, geography, culture, race, gender or
other barriers
! is based on full participation of the community
! emphasises prevention
! addresses the main health problems of the community it serves
! is the main focus of a country’s health system - not a bottom layer added on.
WHO2
The Declaration of Alma-Ata defined primary health care as: ‘Primary Health Care is
essential health care based on practical, scientifically sound and socially acceptable
methods and technology made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and country
can afford to maintain at every stage of their development in the spirit of self-reliance
and self-determination.’2
How do we define primary health?
Primary health means promoting health and preventing illness (eg complications
associated with diabetes) before it occurs.
Trying to create an environment that makes `healthy choices, easy choices' (access to
healthy food, exercise options etc).
Factors affecting health include physical factors, social status, cultural issues,
economic situation and gender environment.

4
Circles of influence (individual in centre, group / family, community, policies, social /
economic).
Primary health care goals for diabetes
Each health service will need to assess its situation and work out individual goals. The
following are general goals which you may wish to consider when working with
individuals to establish personal goals.
Promote health
Promoting exercise, high fibre, low saturated fat, low added sugar eating as the
‘normal’ pattern for the health of all Australians.
Prevent illness
Encourage people to find out whether they are at risk of developing type 2 diabetes, eg
do they have a family history, are they overweight or over 40 years.
Minimise disability
For those who have diabetes (any type), have regular checks with the appropriate
health professionals for early detection and prevention of complications.
Equality of access
Ensure equity of access of people with all types of diabetes.
Equity of outcome
Targeting population(s) who are most at risk of developing type 2 diabetes (eg
Aboriginal).
Overcoming isolation
Provide opportunities for people with diabetes to interact and network with others, eg
support groups.
Disease control
Provide information for all people with diabetes about the range of services / treatments
available.
Circles of influence
Group/family Community
Individual
Policies Social/Economic

5
The process of evaluation
These are some of the steps to be considered in evaluation:
! formal and informal feedback from the participants
! has the program reached its target audience
! has the implementation followed the planning - was planning adequate - was
implementation adequate
! check each aspect of the program - were there any aspects which indicate a
change of strategy
! did the program meet all its goals
! was the program flexible - did it change to meet people’s needs
! relationships between participants and professionals - was power shared?
‘Evaluating the work of your agency or team is a vital process to prevent it wandering
from its original goals or away from addressing the needs of the community you are
working for. Informal evaluation can be incorporated into the normal work of the
agency or team, for example, through discussion and reflection at weekly staff
meetings. It will be necessary, however, for the agency or team to take time out to
evaluate itself more formally, and to involve the community in this process. This can be
done by setting time aside specifically for evaluation and strategic planning.’3
The health care team
A team of health care professionals is available to assist people with diabetes to deal
with specific problems as they arise. The following health professionals may be
included in the care of people with diabetes.
! Aboriginal health worker
! Community health nurse
! Diabetes educator
! Dietitian
! District nurse
! Endocrinologist
! Exercise Physiologist
! General nurse
! General practitioner
! General practice nurse
! Obstetrician
! Occupational therapist
! Ophthalmologist
! Optometrist
! Paediatrician
! Pharmacist
! Physiotherapist
! Podiatrist
! Psychiatrist
! Psychologist
! Social worker
! Surgeon
Remember the most important member of the team is the person with diabetes.
Diabetes mellitus is one disorder where most of the care is provided by the individual
themselves. The individual’s knowledge, skills and attitude for behavioural change are
the essential ingredients of optimal self-care.
To improve health and the quality of life, we, the health professionals involved in
diabetes care, have a responsibility to provide ongoing expertise, information and
psychological support to individuals with diabetes.

6
References
1. South Australian Community Health Association and Primary Health Care Training Project (1992)
The changing face of health - A primary health care casebook. South Australian Health
Commission, Adelaide.
2. World Health Organisation (1978) Report of the International Conference on primary health care -
Alma-Ata, USSR. World Health Organisation, Geneva.
3. Wass A (2000) Promoting health: The primary health care approach. Harcourt Australia,
Marrickville.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009
1
SECTION 2
Understanding diabetes
What is diabetes?
Diabetes mellitus is a condition where high blood glucose levels (hyperglycaemia)
occur. The normal range for blood glucose in a person who does not have diabetes is
between 3 and 8mmol/L. This range is maintained during the individual’s day to day
activities.
Glucose is needed by the body for energy and is obtained from carbohydrate foods
such as starches and sugars. The glucose is transported from the gut through the
portal system to the body. Glucose that is not immediately used is transformed and
stored in the liver. The regulation and storage of glucose is controlled by the hormone
insulin.
Insulin is produced by the beta cells of the pancreas in response to a rise in blood
glucose concentration. The hormone insulin is responsible for the uptake, storage and
use of glucose by the body cells, thus supplying available energy for use in the body.
Without sufficient insulin there will be impaired metabolism, not only of carbohydrates,
but of protein and fats as well.
Classification of diabetes
The different types of diabetes have different causes and clinical presentation. The
common feature for all types of diabetes is hyperglycaemia.
Primary diabetes
Type 1: An absolute deficiency of insulin. The exact trigger is unknown but is an
autoimmune response. Intensive insulin therapy is required for survival.
Type 2: A combination of insulin resistance (a resistance by the cells of
the body to the action of insulin, thereby reducing the effectiveness of insulin) and
insulin deficiency. Type 2 diabetes is a progressive disease that requires ongoing
monitoring. Most people will need to take oral anti-diabetic medication and eventually
many will require insulin.1
Gestational diabetes
Diabetes occurring for the first time during pregnancy and often lasting only for the
duration of the pregnancy. Progression of type 2 diabetes later in life will occur in
5–50% of women with gestational diabetes mellitus (GDM). Around 17% of Australian
women with GDM develop type 2 diabetes within 10 years, and up to 50% within 30
years.2
Secondary diabetes
Diabetes as a result of another disorder, for example: pancreatic disease, endocrine
disorder, drugs, chemicals or other stresses.

2
Features of type 1 and type 2 diabetes
Type 1 Type 2
Characteristics
10 – 15% of all people with diabetes 85-90% of all people with diabetes
no insulin produced insulin resistance and insulin deficiency
some family history usually family history
due to damage to beta cells because of
auto immune response
age, overweight / overwaist, lifestyle
factors
generally occurs in younger people under
40 years but may occur at any age
usually occurs in older people over 40
years, may occur at any age
Onset
rapid onset (weeks / months) gradual onset, often no symptoms
(months or years)
ketonuria often present (due to lack of
insulin)
ketonuria not present as some insulin still
being produced
may present with existing chronic
complications
Treatment
requires intensive insulin therapy either by
multiple injections or insulin pump
initially life style education, and will
require oral medication and/or insulin
therapy after a few years
NB Type 2 diabetes in children
Type 2 diabetes is rapidly increasing in children and adolescents, accounting for
approximately 5 percent of diabetes in this age group in Australia.3
Type 2 diabetes in children presents in a similar way as in adults eg there is insulin
deficiency and resistance. Often children have a strong family history (present in over
80% of cases) and predominately they are obese. Indigenous and some ethnic groups
are at high risk such as Aboriginal and Torres Strait Islanders. Whilst type 2 diabetes
is often asymptomatic it may present with ketosis and even mild to moderate
ketoacidosis in this group. Type 2 diabetes may have a prolonged asymptomatic
phase and so screening for complications should start at diagnosis. Children are at
risk for macrovascular complications due to the underlying metabolic syndrome
associated with type 2 diabetes.3
The treatment is similar to the approach with adults eg lifestyle and medication.

3
Prevalence of diabetes
Results of the AusDiab Study released in April 2001, showed that 1 in 4 Australians
have a problem with glucose metabolism. The study identified that 3.8% of adults (25
years plus) had diagnosed diabetes, 3.8% had undiagnosed diabetes and 16.3% had
either impaired glucose tolerance or impaired fasting glucose.4
Diagnosed 3.8%
Undiagnosed 3.8%
IGT of IFG 16.3%
Total 23.9%
The prevalence of type 2 diabetes rises steeply with age and is estimated at:
25 – 34 years 0.3%
35 – 34 years 2.5%
45 – 54 years 6.2%
55 – 64 years 13.1%
65 – 74 years 18.6%
75 years plus 23.6%
The prevalence of childhood diabetes (type 1) is estimated at:
0-14 years old 22 per 100,000 people
15-24 yrs old 15 per 100,000 people
Over 40 years 5 per 100,000
The latest report published by the Australian Institute of Health and Welfare shows that
the rate of type 1 diabetes is increasing by 3% per year.5

4
Clinical presentation
The classic symptoms of diabetes mellitus include:
! polyuria
! polydipsia
! tiredness / lethargy.
The symptoms of diabetes vary from individual to individual and in relation to the level
of hyperglycaemia. Some people with type 2 diabetes may also be asymptomatic.
Symptoms are similar in each type of diabetes, however, intensity and onset varies.
The following terms describe associated symptoms of hyperglycaemia.
Glycosuria – the presence of glucose in the urine. When blood glucose concentration
exceeds the renal threshold of approximately 10mmol/L in a young person (in older
people it can be higher) glucose is excreted in the urine and is detected with a reagent
testing strip.
Polyuria – excessive urination. Glucose is osmotically active and requires water for
excretion. In uncontrolled diabetes, the filtered glucose `pulls’ large quantities of water
with it which leads to increased urine production.
Polydipsia – excessive drinking. Polyuria causes loss of water, resulting in
dehydration. Dehydration triggers thirst in the person in an effort to replace lost water.
Polyphagia – excessive eating of food. Without insulin, glucose is unavailable to the
cells for energy. The body perceives a state of `starvation’ and the appetite is
increased in an effort to gain enough food for energy. The body also loses nutrients
through the urine (glycosuria, ketonuria).
Weight Loss – in type 1 diabetes, protein and fat stores are broken down to be used
for energy. Ketones are produced and excreted in the urine.
Ketonuria – in type 1 diabetes there may be the presence of ketones in the urine or
blood. When there is not enough insulin to utilise the glucose, fat stores are broken
down for energy, ketones are produced. Moderate to large ketones found in urine or
blood may indicate ketoacidosis, a life-threatening emergency situation.
Tiredness – caused by the inability to utilise glucose, resulting in insufficient energy
supply.
Skin and genital infections – hyperglycaemia results in a lowered resistance to
infection, glycosuria results in thrush (monilia / candida infection), pruritus vulvae or
balanitis.
Blurred vision – due to change in the shape of the lens of the eye because of
hyperglycaemia. Occasionally this is the main symptom and may last several weeks
while blood glucose is being stabilised.

5
Diagnosis and management
Type 2 diabetes
Risk factors and screening
Testing for undiagnosed type 2 diabetes is recommended for the following high risk
Individuals:6
! people with impaired glucose tolerance or impaired fasting glucose
! Aboriginal and Torres Strait Islanders aged 35 and over
! certain high risk non-English speaking background groups aged 35 and over
(specifically Pacific Islander people, people from the Indian subcontinent or of
Chinese origin)
! people aged 45 and over who have either or both of the following risk factors
- obesity (BMI ! 30 )
- hypertension
! all people with clinical cardiovascular disease (myocardial infarction, angina or
stroke)
! women with polycystic ovary syndrome who are obese.
Individuals presenting the following risk factors are also considered to be at high risk of
having undiagnosed type 2 diabetes:
! women with previous gestational diabetes
! people aged 55 and over
! people aged 45 and over who have a first degree relative with type 2 diabetes.
Diagnosis
Diagnosis is based on plasma glucose measurements in conjunction with clinical
assessment.6, 7
Diagnosis is made in one of the following ways but each must be confirmed on a
subsequent day unless unequivocal hyperglycaemia with obvious symptoms are
present.
1. Symptoms of diabetes and a random (non-fasting) plasma glucose >11mmol/L
(random means any time of day regardless of last meal).
2. Fasting plasma glucose >7.0mmol/L.
3. 2-hour plasma glucose >11mmol/L during an oral glucose tolerance test (OGTT).
The OGTT (Appendix 1) is unnecessary to diagnose diabetes in people with an
unequivocally elevated fasting or random plasma glucose. An OGTT should be
performed in a person with an equivocal result. (See Figure 1).
The test is carried out after an overnight fast, following three days of adequate
carbohydrate intake (greater than 150g per day). A 75g load of oral glucose is given
and the diagnosis of diabetes can be made if venous plasma glucose level fasting is
>7.0mmol/L or 2 hour post glucose load is >11mmol/L.

6
A person with type 2 diabetes may first present with long term complications - eg
diabetic retinopathy, neuropathy, coronary artery disease, peripheral vascular disease
and / or cataracts (refer Long term complications – Section 12).
Routine examination may incidentally detect glycosuria and / or hyperglycaemia – eg
during pregnancy or as a result of community screening programs.
"11.1
F or R:<5.5
Diabetes unlikely
F: 5.5-6.9
R: 5.5-11.0
Diabetes likely
F: "7.0
R: "11.1
Diabetes uncertain
2hr glucose levels
7.8-11.0
Re-test yearly if
high risk
3 yearly if
increased risk
Diabetes unlikely
<7.8
F = Fasting
R = Random
Oral glucose tolerance test
Impaired glucose tolerance
Diabetes likely
Glucose levels – venous plasma: mmol/L
Figure 1

7
Ongoing management principles for people with type 2 diabetes
A team approach is essential for the successful management of diabetes, with the
active participation of the person with diabetes and if appropriate including family
members.
Ideal management involves:
! active involvement of the person with diabetes and their family members
! appropriate treatment plan
! appropriate nutrition and weight control
! appropriate exercise / activity program
! advice for maintaining a healthy lifestyle eg stress management, avoiding
smoking
! appropriate safe use of pharmaceuticals as required (oral agents and / or insulin).
The aims of management are to:
! restore the altered metabolism of the person with diabetes and maintain blood
glucose levels within the normal range
! identify and reduce risk factors of diabetes related complications
! prevent or delay progression of the short and long term complications
! empower the person to self manage their own diabetes and restore the individual
with diabetes to as independent a lifestyle as possible
! provide ongoing management, support and resources.
Principles of medical management:
! people with type 2 diabetes usually progress from lifestyle alone, tablets and then
onto insulin8
! type 2 diabetes is a progressive disease which needs progressive increases in
treatment to maintain appropriate HbA1c levels
! oral medications can be combined with insulin.
See Medication - Section 10 for medication pathway in type 2 diabetes.

8
Type 1 diabetes
Diagnosis
Type 1 diabetes can be diagnosed if the characteristic symptoms and signs are present
and the fasting venous plasma glucose concentration is greater than or equal to
7.0mmol/L, and / or the random venous plasma glucose concentration taken at least 2
hours after eating is greater than or equal to 11.1mmol/L. An oral glucose tolerance
test (OGTT) is rarely indicated in diagnosis of type 1 diabetes in childhood and
adolescence.3
A child or adolescent may present with diabetic ketoacidosis (refer
Unstable diabetes – Section 7).
The ‘honeymoon period’ in type 1 diabetes.
The honeymoon period is the time between diagnosis and complete damage to
the beta cells of the pancreas. Initially the person’s pancreas is still producing
some insulin but in decreasing amounts. The person may go from not needing
much insulin to needing some insulin, to being totally dependent on insulin
within a year.
How long the ‘honeymoon period’ lasts varies from person to person but people with
type 1 diabetes will usually be totally dependent on insulin within one year.
Ongoing management principles (refer Children and adolescents – Section 14)
! Children and adolescents with type 1 diabetes should have access to care by a
multidisciplinary team trained in childhood diabetes.
! The older child and the family should be recognised as being part of the
management team.
! Education from a credentialled diabetes educator (where possible) should be part
of the management of type 1 diabetes.
! Education should be adapted to each individual’s age, maturity, stage of
diabetes, lifestyle and culture.
! After the initial period of diagnosis and education (when frequent contact may be
required), the child should be regularly reviewed throughout the year. This should
be no less than 3-4 times per year), including one major annual review (paying
particular attention to growth, blood pressure, puberty, associated conditions,
nutrition and complications) with the multidisciplinary team.
! In rural and remote areas children with diabetes may be successfully cared for by
a local paediatrician / physician with training and experience in paediatric
diabetes, access to resources, support and advice from a tertiary centre diabetes
team.
! The transition from a paediatric to an adult service for the adolescent with
diabetes is often difficult. Transfer to an adult service should be comprehensive
and include a preparation phase and evaluation phase.3
Principles of medical management
! people with type 1 diabetes are dependent on insulin for survival
! insulin must not be stopped under any circumstances
! insulin is not normally used in combination with any other hypoglycaemic agents
! metformin is sometimes used for people with type 1 diabetes who have insulin
resistance but the evidence for its effectiveness is limited.3

9
Gestational diabetes
Risk factors and screening
The Australasian Diabetes in Pregnancy Society (ADIPS) recommends that screening
for gestational diabetes (GDM) should be considered in all pregnant women. Risk
factors for GDM include.9
! glycosuria;
! age over 30 years;
! obesity;
! family history of diabetes;
! past history of GDM or glucose intolerance;
! previous adverse pregnancy outcome; and
! belonging to an ethnic group with a high risk for GDM (Australian Indigenous,
Polynesian and South Asian [Indian] groups; Middle Eastern and other Asian
groups).
Diagnosis
GDM is diagnosed by OGTT (refer Pregnancy – Section 13)
Ongoing management principles (refer Pregnancy – Section 13)
! A team approach is recommended for managing women with GDM and, if
necessary a virtual team could be used.
! The large health services teams would usually comprise an obstetrician, diabetes
physician, a diabetes educator (diabetes midwifery educator), dietitian, midwife
and paediatrician. In country areas management by an obstetrician or obstetric
general practitioner knowledgeable in GDM management in collaboration with a
dietitian, diabetes educator or midwife, is acceptable.9
! Insulin therapy is commenced if fasting blood glucose levels exceed 5.5mmol/L
or 2 hour post-prandial levels exceed 7mmol/L on two or more occasions in one
week.
! Women need to receive appropriate education and support throughout their
pregnancy as well as follow up screening and pre-conception counselling.
Follow up annual screening and pre-conception screening
! Women should be screened for diabetes at 6 weeks post-delivery and 12
monthly thereafter.
! Women need to be informed about the risks for type 2 diabetes in the future and
the need for preconception screening (refer Pregnancy – Section 13).

10
The oral glucose tolerance test
Indications
1. To confirm diabetes when fasting blood tests are inconclusive.
2. Screening for gestational diabetes (refer Pregnancy – Section 13).
Considerations
! Recent illness may give false glucose tolerance test results, therefore it is
preferable to perform the test after at least 2 weeks of good health.
! Adequate dietary carbohydrate for the 3 days prior to the test (! 150g/day). In
most cases this means that the person should have their usual diet.
! Certain drugs, eg hormones, diuretics or steroids, may influence the results,
therefore it is important to record any such drugs on the request form.
! This test is ordered by a doctor.
Preparation
! The test is performed in the morning, after a fast of at least 8 hours (but not more
than 16 hours).
! Water is permitted throughout this period and during the test.
! The person is advised to rest for 30 minutes before and for the duration of the
test. (Sitting in a chair is sufficient).
! No smoking for at least one hour before the test or during the test.
Glucose (75g) in solution is used eg Glucoscan solution.
The dose for children is 7ml of solution (1.84g of glucose) per kg body weight, up to a
maximum of 285ml (75g).
The dose for adults is 75g of glucose in solution.
Procedure
Ensure appropriate pathology request form is completed by a medical officer.
Collect venous blood sample immediately before glucose drink then at 2 hours after
glucose drink.
Note times for fasting and 2 hr bloods, and label bottles correctly.
Appendix 1

11
References
1. National Prescribing Service (2008) Managing hyperglycaemia in type 2
diabetes - Volume 56. National Prescribing Service Newsletter. [Cited 18 May
2009]; Available from:
http://www.nps.org.au/health_professionals/publications/nps_news/current/nps_
news_56/managing_hyperglycaemia_in_type_2_diabetes
2. Lee A, Hiscock R, Wein P, Walker S, and Permezel M (2007) Gestational
diabetes mellitus: Clinical predictors and long-term risk of developing type 2
diabetes. Diabetes Care, 30(4): p878–883.
3. Australasian Paediatric Endocrine Group (2005) Clinical practice guidelines:
Type 1 diabetes in children and adolescents. Department of Health and Ageing,
Canberra.
4. Dunstan D, Zimmet P, Welborm T, Sicree R, Armstrong T, Atkins R, and et al
(2001) Australian diabetes obesity and lifestyle study (AusDiab), International
Diabetes Institute, Melbourne.
5. Australian Institute of Health and Welfare (2008) Incidence of type 1 diabetes in
Australia: First results. Cat. no. CVD 42, Australian Institute of Health and
Welfare, Canberra.
6. National Health & Medical Research Council (2001) Part 3: Case detection and
diagnosis. Evidence based guidelines for case detection and diagnosis of type
2 diabetes. December, NHMRC, Canberra.
7. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes
management in general practice: Guidelines for type 2 diabetes. Royal
Australian College of General Practitioners and Diabetes Australia, Canberra.
8. Nathan D, Buse J B, Davidson M B, Ferrannini E, Holman R R, Sherwin R, and
Zinman B (2009) Medical management of hyperglycemia in type 2 diabetes: A
consensus algorithm for the initiation and adjustment of therapy. Diabetes Care,
32(1): p193-203.
9. Hoffman L, Nolan C, Wilson J D, Oats J J, and Simmons D (1998) Gestational
diabetes mellitus management guidelines. Medical Journal of Australia. 169
p93-97. 18 June 2009. Available from:
http://www.mja.com.au/public/issues/jul20/hoffman/hoffman.html

SECTION 3 – DIABETES EDUCATION AND SUPPORT - REVISED SEPTEMBER 2009
1
SECTION 3
Diabetes education and support
Introduction
The impact of chronic disease and the growing awareness of the role played by people
with chronic conditions in determining their own health outcomes has led to greater
awareness of the role of self management in chronic disease. Similarly, the need to
support people with chronic conditions to acquire self management skills and the
confidence to apply theses skills in everyday living has also led to the identification and
incorporation of self management support and education in a range of chronic disease
models including the National Chronic Disease Strategy1
and the National Service
Improvement Framework for Diabetes.2
Unlike acute medical conditions, chronic conditions are ongoing, with health outcomes
and quality of life dependent on client self management and decision making, and the
availability of ongoing (versus short term) clinical care and support services. Client-
centred approaches in chronic disease management place the person with the
condition as the ‘expert’ rather than the health professional. This does not negate the
need for expert or best practice clinical management but recognises that the person
with the condition has the absolute power of veto over even the most efficacious
clinical management plan.
Diabetes has been considered as one of the most complex of the chronic diseases,
requiring the person with diabetes to juggle a range of daily clinical and lifestyle tasks
in order to avoid the short and long term complications of diabetes. Diabetes self
management education (DSME) aims to build the person with diabetes as an active
member of their diabetes team and ‘to improve health status by empowering the
person with diabetes to;
! acquire knowledge (what to do)
! acquire skills (how to do it)
! develop confidence and motivation to perform appropriate self care behaviours
(want to do it)
! develop problem solving and coping skills to overcome barriers to self care
(can do it).3
The role of health care providers is to support people with diabetes along this path by
providing self management education and support, enabling them to master the tasks
required for effective self care and to become an active participant in their diabetes
management.

2
Goals and outcomes for diabetes education
The report Outcomes and Indicators for Diabetes Education – A National Consensus
Position4
provides a framework for the design and evaluation of diabetes education
programs.
Three overarching goals for diabetes education were identified in this report that
resulted from a review of relevant literature, survey of service providers, extensive
consultation with consumers, service providers and policy makers and a national
stakeholder forum:
! optimal adjustment to living with diabetes
! optimal physical (health) outcomes
! optimal (public and personal) cost effectiveness.
The outcomes associated with the attainment of these goals were identified as:
! knowledge / understanding (including the application of knowledge)
! self management
! self determination
! psychological adjustment
! clinical outcomes
! cost effectiveness.
The above outcomes were defined as the results of diabetes education. Indicator
areas were identified for each outcome. Indicators are defined in the report as the
units of information that can measure progress towards achievement of the result.

3
Chronic disease self management and diabetes self
care behaviours
There are two widely accepted models for generic chronic disease self management
support. The chronic disease education models arising from Stanford University5
and
the Flinders Human Behaviour & Health Research Unit6
identify common tasks that a
person needs to achieve in order to successfully manage a chronic condition.
Stanford University
Flinders Human Behaviour & Health
Research Unit
! recognising and responding to
symptoms
! using medications
! managing acute episodes and
emergencies
! maintaining good nutrition
! maintaining adequate physical
activity
! not smoking
! using relaxation and stress reducing
techniques
! interacting appropriately with health
care providers
! seeking information and using
community resources
! adapting work and other role
functions
! communicating with significant
others
! managing negative emotions and
psychological response to illness
! know about the condition and
various treatment options
! be actively involved in decision
making in relation to treatment and
management of the condition
! follow the treatment plan developed
with health care providers
! monitor symptoms and take
appropriate action to manage and
cope with symptoms
! manage the physical, emotional and
social impact of the condition on
their life
! adopt a lifestyle that promotes
health and does not worsen
symptoms.
The Stanford Model is underpinned by self efficacy theory which is premised on the
following: belief in one’s ability to perform tasks is a good predictor of motivation and
behaviour; self efficacy can be enhanced through skills mastery, goal attainment,
modelling and social persuasion; improved self efficacy leads to improved behaviour,
motivation, thinking patterns and emotional well being. The Flinders Model also
identifies the Transtheoretical Model as a useful model to guide health professional
interventions which should be characterised by collaborative goal definition; targeting,
goal setting and planning; training and support for individuals to change; active and
sustained follow-up. The Stanford Model focuses on peer leadership and generic skill
development while the Flinders Model is clinician led and is designed to be integrated
with medical management.

4
The self management tasks identified by these self management models are congruent
with the self care behaviours identified in a technical review undertaken by American
Association of Diabetes Educators (AADE) as being key behaviours for effective
diabetes self management.3
AADE Diabetes Self Care Behaviours
Healthy eating
Being active
Monitoring
Taking medication
Problem solving
Healthy coping
Reducing risks
With permission from the AADE, the Australian Diabetes Educators Association
(ADEA) has adopted the AADE self care behaviours and published them in Diabetes
Self Care – the 7 Steps to Success.7
The self care behaviours provide an easily understood framework and a common
language for people with diabetes and diabetes educators to discuss health behaviours
and their associated risks and benefits.

5
Health behaviour and health education theory
Health behaviour and health education theories provide frameworks in which to
consider why knowledge may not be translated into action, why people may or may not
adhere to treatment recommendations and strategies that can be utilised to support
behaviour change. The Outcomes and Indicators Framework identified self
management and self determination as two outcome areas most impacted on by
diabetes education, after knowledge and understanding. The following theories
provide insight into these concepts and practical strategies to achieve these outcomes.
The Health Belief Model8
identifies that in order to adopt a behaviour (eg engage in
self care practices), a person must believe they are at risk of an adverse event (eg
diabetes complications), that the consequences of the event are severe and that the
event can be avoided by a particular treatment or engaging in a particular behaviour.
The likelihood of a person adopting the behaviour depends on how they perceive the
benefits as opposed to the barriers (or costs) of adopting the behaviour.
Self Determination Theory4
describes autonomous motivation versus controlled
motivation – doing something because one wants to do it versus being coerced to do it
(including health professional pressure or pressure to appease a health professional).
Autonomous motivation is associated with greater likelihood of success in adopting and
sustaining a behaviour and is associated with the absence of threats and external
rewards. An autonomous environment offers choice and the opportunity to discuss and
acknowledge feelings.
Self efficacy is one of the five domains of self determination identified in the Outcomes
and Indicators Framework. Self efficacy is also one of the key constructs of Social
Cognitive Theory.8
People develop self efficacy through experiencing success.
Social Cognitive Theory embodies the following strategies for health behaviour
interventions:
! providing opportunities for social support
! promoting capability and mastery through skills training
! modelling positive outcomes of healthy behaviours
! describing outcomes of change that are meaningful to individuals
! promoting individual regulation of goal directed behaviour through providing
opportunities for decision making, self monitoring, goal setting, problem solving
and intrinsic (self) reward
! providing opportunities for observational learning and opportunities to learn from
credible models (e.g., peers)
! supporting self initiated rewards / incentives
! approaching behaviour change in small steps and being specific about the
change
! providing training in problem solving and stress management, including the
opportunity to practice skills in challenging situations.
The Transtheoretical Model8
identifies the various stages of change that individuals
move through in order to adopt and maintain a behaviour: pre-contemplation;
contemplation; preparation; action; and maintenance. Other important concepts of the
Transtheoretical Model are decisional balance (the benefits versus the costs of
changing) and self efficacy (confidence that one can engage in healthy behaviours
across a range of challenging situations versus temptation to engage in unhealthy
behaviours). The Model also clearly identifies that different strategies are required for
each ‘stage of change’ and applying strategies suitable for one stage at another may
be counter productive. Given the range of self care behaviours that people with
diabetes are required to contemplate, it is important to recognise that individuals may
be at different stages of readiness for each one.

6
Delivery of diabetes education
A Cochrane Review9
examining the impact of group training in diabetes self care
concluded that group programs impacted favourably on a range of clinical diabetes
outcomes.
The NHMRC Patient Education Guideline for Type 2 Diabetes10
identifies the following:
! Both group and one-to-one diabetes client education provided on a face to face
basis have a positive impact on knowledge, lifestyle change and some aspects of
psychological outcomes.
! Interventions delivered over the longer term and those with regular reinforcement
are more effective than one-off or short term interventions.
! Multidisciplinary team delivery may provide better client outcomes.
Program aims
The overall aim of diabetes education is to support people with diabetes to acquire the
knowledge, skills and confidence to engage in effective diabetes self care practices
and be pro-active members of their diabetes care team.
The specific objectives could be to:
! enhance self efficacy
! facilitate the adoption of self care behaviours
! reduce diabetes related distress.
To be effective, education should be designed to build on the person’s own life skills
and behaviours. It should be sensitive and relevant to the individual’s needs, goals
and their perception of their illness. Changing behaviour will depend on the educator’s
approach to the person’s beliefs and the knowledge the person already has.
People change their behaviour when:
! they believe their illness will affect their lives
! they are confident that they can positively affect the outcome of their illness
! they believe the benefits outweigh the disadvantages of change
! they are confident that they can succeed
! it will help them achieve their own personal goals.
Recommendations and advice given to people should be based on careful
assessment of the individual’s needs and priorities. It is essential to have a broad
based knowledge about emotional, cultural and social circumstances. Achievable
goals need to be negotiated with the individual.
Educational programs should be planned bearing in mind that any illness and / or
admission to hospital can cause regression in an individual’s coping mechanisms and
emotional responses. This can cloud the person’s normal judgment and impede
learning.

7
Teaching tips
! Use correct but simple terminology.
For example: `glucose’ is preferable to `sugar’. People can then relate glucose
not only to simple sugars but to carbohydrates as well.
! Having ascertained what people already know, work from that to new areas of
information.
! Having ascertained what worries or concerns the person, work to address these
as a priority.
! Work from simple to more complex information.
For example: teach the relationship between diet and blood glucose, before
expecting people to plan a menu.
! Relate what is currently being taught to the learner’s past experiences.
For example: `How did you feel yesterday?’
`I felt weak, I was sweaty and unsteady on my feet.’
`Your blood glucose level may have decreased, maybe
you had a hypo.’
! Encourage active participation in the teaching session.
For example: ask the person to describe how they might explain an aspect of
diabetes self-care to a friend or relative.
! Demonstrate skills - person performs skill with you / person performs skills
independently with your support / supervision.
! Referring to written step by step information that person may refer to if educator
is not present.
! Ask the person to recall information.
For example: `What happens to the glucose concentration in the blood of a
person with diabetes?’
! Repetition and reinforcement of information will aid learning.
! It is important to give positive feedback.
For example: say that they have done well to have retained information from a
previous session. Commend further reading undertaken on diabetes. Reinforce
the positive benefit of asking questions. This will give a sense of achievement,
direction and control.
! Use a variety of teaching methods.
For example: groups
one to one sessions
videos
drawings / diagrams
demonstration practice.
! Leave person with written handouts on subjects covered that will reinforce the
information given or skills taught.

8
Evaluating teaching effectiveness
The questions the person asks will assist in showing what they have learnt.
Accept the person’s right not to follow any / all of the recommendations at the time of
teaching. They may take these up later.
People have individual health beliefs and values.
For some people, the need to avoid alcohol, cigarettes, fatty foods and excess calories
conflicts with perceived rights for social acceptance, pleasure, gratification and tension
reduction.
Therefore, some people need help in substituting one value for another. A new value
must be equally rewarding if the behaviour is to be changed.
For example: Not smelling of smoke when smoking is stopped.
Wearing new clothing after losing weight.
Feeling better when controlling blood glucose concentrations.
Being able to work better when exercising / reducing alcohol
intake.
Printed text should be provided to reinforce information given and should be specific to
the areas addressed.

9
Evaluating an education program or service
Evaluation can be formative or summative. Formative evaluation focuses on the
processes of a program eg to find out if improvements or adjustments are needed to
achieve the educational outcomes. Evaluating processes is a way of monitoring the
implementation of the program. The summative evaluation is focused on assessing
what outcomes have been achieved from the program eg long term effects of a
program.
The first phase for evaluating a program or service can be done using a formative
approach as this will inform further adjustments/improvements to the education
program or service.
Formative evaluation
1. Service capacity measures
! total occasions of service
2. Service reach measures:
! number of referrals for education versus prevalence of type 2 diabetes for a
given geographical area
! number of referrals for education of gestational diabetes (GDM) versus
incidence of GDM for region.
3. Efficiency measures:
! number of people attending the initial group program versus numbers
attending further education sessions
! number of people who actually attended versus number booked in
! number referred to other health service providers.
4. Surveys
! can be used at the end of each session to get a general feel for how the
clients felt after the session. See Appendix 1 for an example of a consumer
satisfaction survey.
Summative evaluation
The report Outcomes and Indicators for Diabetes Education – A National Consensus
Position (Outcomes and Indicators Framework 2007) provides a framework for the
design and evaluation of diabetes education programs. Some of the outcomes related
to diabetes education from this report were identified as:
! knowledge / understanding (including the application of knowledge)
! self management
! self determination
! psychological adjustment
! clinical outcomes
Some of the tools that can be used pre and post education to assess outcomes can be
accessed via the Diabetes Outreach website www.diabetesoutreach.org.au.

10
Another method for evaluating outcomes can be though the client setting their own
personal goals. Explain that goals focus on:
! Actions – not attitudes (stop feeling worried)
! Something to do or start doing – not something to stop doing
! One action at a time
! Actions that individuals feel are achievable – even if they pose a bit of a
challenge
! Actions that are personally meaningful.
You can explain the SMART goal acronym, giving examples. Goals should be:
! Specific – exactly what will you do? eg I will walk for 30 minutes.
! Measurable – how much / how often are you going to do this? eg three
times a week.
! Achievable – how confident are you that you can do this? On a scale of 1
– 10, confidence should be rated at least 7, otherwise the goal may be
unattainable.
! Realistic – is this something that really can be done?
! Time frame – be specific about the time frame in which you are going to
achieve this eg I will achieve this by the end of next week.
See Appendix 2 for an example of a goal setting sheet.
We would like to acknowledge the contribution by Kaye Neylon to this section of the
Manual (2009) and her work on the 7 steps education and support program.

11
SATISFACTION SURVEY
SERVICE ACCESS Yes No
Were you able to get an appointment as soon as you wanted?
Was the appointment at a venue and time that suited you?
RESPECT FOR YOUR WISHES Yes No
Did the diabetes team member(s) listen to what you had to say?
Were you involved in decisions about your diabetes education plan?
INFORMATION AND EDUCATION Yes No
Did you get as much information about your diabetes and its treatment as
you wanted?
Did the diabetes team member(s) listen to your questions?
Did the diabetes team member(s) explain things to you in a way you could
understand?
EMOTIONAL SUPPORT Yes No
Did you have any concerns that you wanted to discuss but did not?
Did you have confidence and trust in the diabetes team member(s)?
Did the diabetes team member(s) ask about how your living situation might
affect your health?
COORDINATION OF CARE Yes No
Were you clearly told about where and when your appointments would be?
Did you ever feel that members of the diabetes team did not talk to each
other enough about your care or situation?
Did you have any follow-up visits that you felt could have been avoided by
better coordination?
Did you feel the diabetes team member(s) communicated appropriately with
your doctor?
Appendix 1

12
Being active
The purpose of this module is to:
! describe the relationship between physical activity, diabetes control and risk factors for the development of complications
! discuss physical activity and exercise recommendations for people with type 2 diabetes
! discuss precautions for people with type 2 diabetes engaging in exercise
! assist participants to develop a personal physical activity plan.
Participant learning outcomes
At the completion of this module, participants will be able to:
! identify personal benefits of physical activity and planned exercise in their diabetes management
! identify personal barriers to engaging in physical activity / exercise and use a problem solving approach to overcoming them
! state precautions to be taken by people with type 2 diabetes engaging in exercise.
Goal setting
S: Specific Specific, concrete goals to describe what the aim is.
M: Measurable Make sure there is an inbuilt measure so that it is clear when the goal has been accomplished.
A: Action oriented Make sure there is a description of how the goal will be achieved.
R: Realistic Set achievable and realistic goals that are geared towards success not failure.
T: Time-boundGoals that have a time frame can be measured and reset.
Being Active example
Eg I'm going to start exercising. This does not meet the criteria for a SMART goal
Instead try
‘I'm going to walk for 20 minutes on my lunch break three times a week for the next four weeks.’
This goal clearly states what the person will be doing, when they will be doing, and for how long. It seems realistic and after four weeks it can be evaluated
and changed as required. The aim of the goal is to take small steps that will lead to the larger overarching goal of ‘being active’. If the person wasn’t
reaching their goal then it is important to look at what the barriers are eg using the example above perhaps the person has been skipping their lunch break
because they have too much work to do. Whatever the reason, it's an indication that the goal needs adjusting. The person might decide to walk after
supper for twenty minutes instead. It is important to change the goals so that the person can succeed.
Appendix 2

13
Being Active – Goal setting record
Follow up
Date Client goal Barriers identified Confidence
(scale 1-10)
* Date Goal Achieved Outcome
*Note: if the person does not score 7 (on a scale of 1-10) then they should be encouraged to re-frame their goal

14
References
1. National Health Priority Action Council (2006) National chronic disease strategy,
Australian Government Department of Health & Ageing, Canberra.
2. National Health Priority Action Council (2006) National service improvement
framework for diabetes, Australian Government Department of Health & Ageing,
Canberra.
3. Mulcahy Kathryn, Maryniuk Melinda, Peeples Malinda, Peyrot Mark, Tomky
Donna, Weaver Todd, and Yarborough Peggy (2003) Diabetes self-
management education core outcomes measures. The Diabetes Educator,
29(5): p768-803.
4. Eigenmann C and Colagiuri R (2007) Outcomes and indicators for diabetes
education - a national consensus position. Diabetes Australia, Canberra.
5. Stanford University School of Medicine (2009) Chronic disease self-
management program. [Cited 29 April 2009]; Available from:
http://patienteducation.stanford.edu/programs/cdsmp.html
6. Flinders Human Behaviour & Health Research Unit (2006) The 'Flinders Model'
of chronic condition self-management. [Cited 29 April 2009]; Available from:
http://som.flinders.edu.au/FUSA/CCTU/self_management.htm
7. Australian Diabetes Educators Association (2008) Diabetes self care - the 7
steps to success. Australian Diabetes Educators Association, Canberra.
8. Glanz Karen, Rimer B K, and Lewis F M. eds (2002) Health behaviour and
health education. 3rd Edition. John Wiley & Sons, San Francisco.
9. Deakin T A, McShane C E, Cade J E, and Williams R D R R (2005) Group
based training for self-management strategies in people with type 2 diabetes
mellitus (Review). Cochrane Database of Systematic Reviews, (2)
10. National Health & Medical Research Council (2008) NHMRC Patient education
guidelines: DRAFT. NHMRC, Canberra.

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009
1
SECTION 4
Hospitalisation
People with diabetes can be admitted to hospital for a range of health problems.
Sometimes the admission is related to the chronic complications of diabetes and
sometimes the admission is not caused by diabetes. Examples of related conditions
include coronary artery disease, cerebrovascular accident, renal disease, or vascular
problems. Problems directly related to diabetes requiring hospitalisation include the
acute complications; diabetic ketoacidosis, non-ketotic hyperosmolar collapse / illness
and severe hypoglycaemia. Sometimes people are admitted for the initiation of insulin
therapy in special situations, eg insulin pump insertion, continuous blood glucose
monitoring. Whatever the reason for admission to hospital it is very important to
manage blood glucose for the best outcomes possible.
Section 4 consists of the following topic areas:
1. Admission procedures.
2. Diabetes management principles.
3. Peri-operative care.
4. Management for radiological procedures.
5. Inpatient diabetes management guidelines (where diabetes is a co-morbidity not
primary reason for admission).
6. Managing acute complications in hospital (hypoglycaemia, diabetic ketoacidosis
and hyperglycaemic hyperosmolar state.
7. Insulin pump therapy.
You may like to refer to the glossary and list of abbreviations contained at the back of
this section.
Admission procedure
The nursing assessment indicates the reason for admission, and should be clear if
diabetes is the reason for the admission or a co-morbidity.
Type of diabetes should be documented as either:
! type 1
! type 2
! type 2 diabetes – insulin requiring.
Assessment
Confidentiality of information and the person’s privacy must be maintained.
The interview process may be conducted formally or while admitting the person, ie
during observations, ward orientation or physical assessment.
! Relevant medical history, including hypoglycaemia unawareness, foot problem.
! Physical assessment, comprehensive head to toe assessment.
! Patient education and assessment of knowledge, skills and attitude, and
modification of self care action plans (Appendix 1).
! Discharge plan.

2
History – specific to diabetes
A comprehensive history provides health care providers with the information
needed to provide adequate care and education. The Queen Elizabeth Hospital
Assessment Standards have been used to underpin the following
recommendations.1
Specific symptoms:
! altered vision (blurring)
! polyuria
! polydipsia / dry mouth / fruity breath
! polyphagia / abdominal pain
! weight loss / weight gain
! nocturia / frequency / burning on micturition / thrush
! malaise / fatigue
! neuropathic sensations in feet (burning).
Diabetes history:
! family history of diabetes / cardiac history (elevated BP / lipids)
! duration and type of diabetes (self and family members)
! ethnic group
! obstetric history of large babies / gestational diabetes
! current glycaemic control and self-management
! diabetes education – knowledge / skills / attitude – prior learning
! recent surgery or glucocorticosteroids, recent illness.
Identifying risks:
! hypoglycaemia risk (also hypoglycaemia unawareness)
! smoking
! foot risk status
! hyperglycaemia
! hypertension
! hyperlipidaemia
! alcohol intake
! activity levels.
Attitudes / cultural beliefs / socialisation / literacy
! all people with diabetes should have an opportunity to discuss their self
management issues with qualified health professionals.

3
Physical assessment
Weight (kg) calculate body mass index which is weight in kilograms
and Height (m): divided by height in metres squared. Healthy range is equal to
or less than 25, suitable for use with both men and women from
age 18 years onwards.2
Waist <94cm for men
<80cm for women
Blood pressure lying and standing
Eyes visual aids used
changes in vision noted by person
date of last ophthalmological or optometry review
Feet sensation and circulation (conduct a foot risk assessment)
(see Footcare – Section 6).
skin integrity
interdigital problems (cracked or macerated skin)
abnormal bone structure of feet
date last seen by a podiatrist, if at all
Blood glucose aim for fasting or pre-meal, if random test done note time of last
meal
Urinalysis microalbumin
ketones
nitrites and / or cells / leucocytes
glucose
Self care
! Medications.
! Self administration of insulin.
! Hypoglycaemia action plan.
! Foot care.
! Sick day action plan.
Education (see Diabetes education – Section 3 and Appendix 1)
! Health maintenance knowledge deficits.
! Emergency care.
! Medication therapy.
! Impending procedures / surgery.
Negotiate a management and education plan to address the identified needs with the
individual, listing objectives and expected outcomes.
Referral options
! Diabetes educator.
! Dietitian.
! Or other relevant health professionals as deemed necessary, eg social worker,
psychologist, podiatrist, vascular nurse, eye department, aboriginal health
worker.

4
Discharge planning
A planned discharge is vital. This should begin on admission to hospital.
Appropriate information for long term care should be supplied to the person with
diabetes and to family members. This will assist the person and family to continue self-
management after discharge.
Ensure the person is registered with the National Diabetes Services Scheme and has
adequate supplies of:
! syringes / pen needles
! monitoring equipment
! medication
! ensure a plan for access to supplies over public holidays and weekend breaks.
Ensure the person is aware of resources for ongoing supplies, eg Diabetes Australia,
National Diabetes Services Scheme (see Resources – Section 15).
Ensure appropriate outpatient appointments have been made, eg doctor, dietitian,
diabetes educator, podiatrist, ophthalmologist / optometrist.
Assess the ability of the person with diabetes and the family to cope at home
and within the community.
Is there a need for extra involvement of family or of community resources?
Are they aware of their long term medical needs, monitoring and liaison with their local
doctor?
Ensure the person is aware of the role of their local doctor. The general practitioner is
often the principal medical professional, in other instances there may be a `shared-
care’ arrangement between specialist, general practitioner and diabetes educator.
Regular follow up visits are encouraged and offer a great opportunity for the general
practitioner to get to know the person and explore the person’s understanding, fears
and concerns about diabetes.
Ensure the person is aware of where to seek assistance / advice for problems
and emergency treatment.

5
Diabetes management principles
This section has been designed to provide information about the diabetes management
of patients where diabetes mellitus is a co-morbidity and not the primary reason for
admission. For information about acute complications of diabetes see page 18 of this
section.
General management principles include:
! Blood glucose levels as close to normal as possible improves in-hospital
morbidity and mortality rates. Aim for target blood glucose levels (BGL)
5.0 - 10.0mmol/L.3
! Never stop insulin in type 1 diabetes.
! Avoid routine use of sliding scale insulin - this destabilises diabetes in most
patients. Sliding scale insulin should only be used for patients who are fasting
and in limited circumstances.4
! Insulin regimens should target prospective / anticipated blood glucose levels
rather than react retrospectively to previous BGLs.4
! Avoid random use of short acting insulin in response to a single elevated BGL
unless patient is symptomatic, especially overnight. It is better to adjust the
overall regimen to prevent further rises in BGL values.4
! Adjust insulin daily to meet target BGL.
! If at any stage diabetes management is unclear or targets are not being met
contact general practitioner or diabetes specialist (eg endocrinologist) if
appropriate.4
Improving glycaemic control
Oral hypoglycaemic agents (OHA) (see table 1; page 15)
! Oral hypoglycaemic agents which are started or increased during hospitalisation
generally do not act quickly enough to control hyperglycaemia.
! Inpatients who have adequate diabetes control and there are no
contraindications (eg patient is not acutely sick or renal impairment) OHAs can
continue to be used.
Subcutaneous insulin
! Supplementary basal insulin (see table 2; page 15).
! Basal / bolus intensive insulin regimen (see table 3; page 16).
! Changing usual insulin regimen (see table 4; page 17).
! Sliding scale insulin for patients who are fasting (see table 5; page 17).
Intravenous insulin / glucose infusion
In many cases, an intravenous insulin / glucose infusion would be used if patient
requires insulin and is fasted for a prolonged period of time (more than 6 hours) or
patient is very unstable. An insulin / glucose infusion protocol must be followed.
Examples and advice around the use of these protocols can be accessed from
hospitals such as the Royal Adelaide Hospital (RAH), Lyell McEwin Hospital (LMH) and
Flinders Medical Centre (FMC).

6
Monitoring
Blood glucose
! As a general guide BGL’s should be checked pre-meal (within 30 minutes pre-
meal) and 2100 hours for all patients who are not on IV insulin (0200 BGL should
be measured only if overnight hypoglycaemia is suspected).4
! The frequency for monitoring BGL needs to be assessed regularly and any
changes documented. If not requiring adjustment to OHAs or insulin therapy and
BGLs in target for 24 hours consider reducing the number of BG tests per day. If
fasting BGL is out of target do more testing that day.
! Notify GP / MO if BGL is greater than 15mmol/L on 2 consecutive readings or any
BGL greater than 20mmol/L.5
(Refer to Unstable diabetes – Section 11 for
further information about hyperglycaemia).
Ketones
! Check for urinary or blood ketones in patients who are on insulin if BGL
persistently >15mmol/L or if the patient is very ill. 4
! If urine ketone levels 3+ or blood ketone levels are above 1.5 or ketoacidosis
suspected, contact the GP / MO or diabetes specialist (eg endocrinologist)
immediately.4
Special circumstances
Enteral or parenteral nutrition
Patients with diabetes who are commenced on enteral or parenteral nutrition may need
significant adjustments to the type, doses and / or timing of their diabetes treatment.
! GP / MO to assess the most appropriate treatment regimen, preferably at the
commencement of enteral / parenteral feeding.
! Monitor BGLs 4 times per day – more frequently if appropriate.
! Remember to recommence an appropriate insulin / medication regimen when the
feeds are ceased and regular oral intake resumes.4
Patients on glucocorticoids
! Patients with diabetes who are commenced on prednisolone, dexamethasone or
other glucocorticoids will experience elevated BGLs.
! BGLs should be monitored 4 times per day and diabetes treatment intensified to
keep BGL in target.
! Remember to adjust diabetes treatment downwards as dose of steroids are
reduced and ceased.4

7
Peri-operative care
Optimal blood glucose levels prior, during and after surgery will assist with wound
healing, reduce the risk of post-operative complications and shorten hospitalisation
period. Surgery tends to cause an increase in blood glucose levels. Therefore, an
increase in oral hypoglycaemic doses or insulin may be required for an extended
period eg while the person is under stress and relatively inactive post-operatively.
Pre-op care
Admission the day before surgery may be advisable to thoroughly assess and establish
monitoring and treatment plans in a person who:
! has type 1 (or type 2 diabetes, insulin requiring)
! is not well controlled
! is having major surgery and / or is likely to have nothing by mouth for a prolonged
period pre or post-operatively.
It is important that an anaesthetist be consulted as part of the patients pre-anaesthetic
work-up or that the patient’s management is discussed with the anaesthetist. Advice
regarding insulin regimens can be obtained by contacting an endocrinologist if
necessary (eg by phone if not available in person).
People with type 2 diabetes and on Metformin should have their Metformin ceased 48
hours prior to surgery. Sulphonylureas will need to be withheld on the day of surgery
(long acting sulphonylureas such as Glibenclamide may need previous night’s dose
withheld).
Management is determined by the results of blood glucose monitoring, and whether the
person is eating or not.
* ALL people with diabetes should have their blood glucose level checked within 1
hour prior to going to theatre. Report to the anaesthetist if the level is <5mmol/L or
>10mmol/L.
People with type 1 diabetes are particularly at risk from ketosis. Notify GP / MO if
ketones are present in blood or urine.
Before giving insulin to a person who is fasting make sure there is an IV glucose
infusion in place running at an appropriate rate.
Intra-op care
! The type of IV fluid given will depend on whether the person is receiving insulin
or not. Glucose infusion must be used if patient has received insulin prior to or
during surgery.
! Monitor BGL at least 2 hourly (1 hourly if IV insulin / glucose infusion in situ).

8
Post-op care
Check blood glucose on arrival in recovery:
! then 4-6 hourly (or 1 hourly for continuous insulin / glucose infusion) for 24 hours
or until stable and eating
! then before meals.
All people with type 1 diabetes require a check for ketones:
! at least 8 hourly
! more frequently if blood glucose >15mmol/L, if the person is vomiting or is
generally unwell.
Before discharge, the person should be advised that their medication dosages should
return to pre-operative doses as they recover and become more active.
Recommence anticipated discharge regimen for at least 24 hours prior to
discharge.

9
Management for radiological procedures
To minimise problems all people with diabetes should be booked into the earliest
possible appointment time.
The Radiology Department should be informed that the person has diabetes and of
their current medication.
Ensure the GP / MO has discussed the procedure with the person and obtained
consent (if applicable). Medication orders may be modified according to the type of
diabetes and medication, and the type and time of procedure. Reduction in dosages
requires discussion with the GP / MO and the person with diabetes.
Well controlled by diet or oral hypoglycaemic agents
The person should omit the morning dose of tablets if fasting is necessary.
Note: Metformin should be stoped 48 hours prior to preparation and ensure
serum creatinine level assessed before restarting Metformin.
Receiving insulin
If fasting, as per inpatient guidelines. Individual advice is essential based on type
of diabetes and insulin schedules.

10
Precautionary measures
Blood glucose monitoring equipment should be accessible for use by an accredited
nurse in the Radiology Department.
Blood glucose should be checked before, during and after the procedure, if the person
feels unwell or complains of hypoglycaemic symptoms.
All people with diabetes should bring the following to the Radiology Department as a
precaution:
! quick carbohydrate eg sugar containing soft drink, glucose tablets - in case of a
hypoglycaemic episode
! Radiology Department should have a hypoglycaemia protocol, hypoglycaemia kit
and blood glucose meter on the emergency trolley for treatment of
hypoglycaemia.
Special precautions may be necessary for people having any radio contrast study
(even using low ionic agents). This includes angiography, CT scan with enhancement
intravenous pyelography.
Those at special risk of problems include those with:
! impaired renal function – creatinine clearance less than 30ml per minute.
In elderly people glomerular filtration rate (GFR) may be significantly reduced in
the presence of a marginally increased or normal plasma creatinine.
! dehydration or effective reduction in blood volume
For example, people with congestive cardiac failure, hypotension, septic shock or
intensive diuretic therapy.
! other nephrotoxic drugs or concomitant medications that may contribute to
decreasing GFR
This includes medications such as gentamicin, diuretics, angioconverting enzyme
inhibitors, angiotensin II receptor antagonists, non-steroidal anti-inflammatory
medications, cyclo-oxygenase 2 inhibitors, cyclosporin, vancomycin, tacrolimus,
amphotericin and others.
If radio contrast studies are necessary, the following precautions should be considered
by the GP / MO:
! stopping other medications several days before the procedure (eg diuretics, non-
steroidal anti-inflammatory drugs)
! hydration before, during and after the procedure using intravenous saline.
After the procedure
Once eating / drinking, recommence medications (except for Metformin – ensure serum
creatinine is normal prior to re-starting this).
It may be necessary to reduce the dose of insulin if food intake is reduced. Discuss
medication adjustment with the GP / MO or diabetes educator.

11
Guidelines for inpatient diabetes
management
The following material is based on the Royal Adelaide Hospital (RAH) Inpatient
Guidelines (2008).4
The guidelines are not to be used for patients who are receiving
enteral or parenteral nutrition. They are not to be used for patients who have been
admitted with unstable diabetes as the primary diagnosis such as diabetic ketoacidosis
(DKA) or hyperglycaemic hyperosmolar state (HHS).
There are 5 guidelines to assist with practice:
1. Patient is eating (figure 1).
2. Patient is not eating or will fast >6 hours after a procedure (figure 2).
3. Patient is not eating but will eat within 6 hours of procedure (figure 3).
4. Hypoglycaemia (figure 4).

12
Figure 1
Patient is eating
BGL in target majority of the time
(within a 24 hour period):
! Continue monitoring BGL
! Continue usual diabetes
medication
! GP / MO to adjust doses if
hypoglycaemia occurs
3 regular meals
(NOT enteral or parenteral)
EATING
Patient on oral
hypoglycaemic agent
(OHA) or diet only
Patient on insulin
1. If BGL > than target for more than 24 hours
make incremental increases of OHA to the
maximum daily dose if required (table 1) OR
2. Add supplementary insulin to OHA (table 2)
3. If BGL still above target use basal / bolus
intensive insulin regimen (table 3)
1. Increase patient’s usual
insulin dose (table 4)
2. If BGL still not in target
within 24 hours use basal /
bolus insulin regimen
(table 3)
Recommence anticipated discharge regimen for
diabetes at least 24 hours prior to discharge
Diabetes target BGL
5-10mmol/L
1. BGL not in target
OR
2. Intercurrent illness / infection that
would benefit from tight control

13
Figure 2
Management of a patient who is NOT eating or will fast
for >6 hours after a procedure
* If you wish to use an insulin infusion and require a protocol please contact RAH, LMH or FMC.
# Refer to page 7 of this section for information on pre-op, intra-op and post-op BGL monitoring.
Patient on oral
hypoglycaemic
agent (OHA) or diet
Patient on insulin
Commence IV 5% glucose at
80-100mls/hr
Check BGL prior to procedure
Give half the usual morning
s/c insulin dose on arrival to
unit on day of surgery
Commence s/c sliding scale
(table 5)
Check BGL 6 hourly #
Continue s/c sliding scale and
5% glucose IV until patient is
eating solid food 3 times a day
Recommence discharge
insulin regimen at least 24
hours pre-discharge
If BGL >10.0mmol/L If BGL <10.0mmol/L
Commence IV 5%
glucose 80-100mls/hr
and s/c sliding scale
insulin * (table 5) If BGL
>10.0mmol/L
When eating regularly:
! recommence OHA
OR
! basal / bolus if more
intensive treatment
required
Schedule patient first on the list for procedures
1. Patient fasting for >6 hours after a procedure
OR
2. Patient nil orally for >6 hours & NOT on enteral or
parenteral nutrition
Monitor BGL four
times per day
Withhold OHA on the morning
of the procedure (metformin 48
hours prior)

14
Figure 3
Management of a patient who is FASTING but will eat
within 6 hours of procedure
Patient fasting but will recommence oral diet within 6 hours after a procedure
If patient for procedure, schedule patient first on the list
Commence 5% glucose IV at
80-100ml/hr at 0600 or on
admission to pre op area
Give half the usual morning s/c
insulin dose on arrival if day of
surgery
Check post-op BGL.
If >10.0mmol/L GP / MO to
review and order single dose
of Actrapid (table 5)
Recommence patient’s usual
insulin with the next meal
If patient unable to eat or
tolerate diet refer to
information on patient fasting
Withhold OHA on the morning
of the procedure (metformin
48 hours prior)
Check BGL within 1 hour before
and after procedure
After procedure
If BGL >15.0mmol/L:
1. GP / MO to review and order
4 units of Actrapid
2. Check BGL four times per
day.
3. If BGL remains above
target follow (figure 1)
When eating regularly:
! recommence OHA OR
! basal / bolus if more
intensive treatment required
Patient on insulin
Patient on oral hypoglycaemic
agent (OHA) or diet

15
Table 1
Oral Hypoglycaemic Agents (OHA)
Name Tablet Strength Maximum daily dose
Metformin 500mg, 850mg, 1000mg 1000mg TDS if CrCI > 90mL/min
1000mg twice daily if CrCI 60-90mL/min
500mg twice daily if CrCI 30-60L/min
Metformin XR 500mg 2000mg night if CrCI>90mL/min
1000mg night if CrCI 30-60mL/min
Cease Metformin if CrCI < 30mL/min
Glibenclamide 5mg 10mg twice daily
Gliclazide MR 30mg 120mg morning
Glimepride 1mg, 2mg, 3mg, 4mg 4mg morning
Glipizide 5mg 20mg twice daily
Table 2
Supplementary basal insulin:
! Supplementary insulin can be added in conjunction with OHA in situations
where a temporary rise in BGL occurs: eg: patient on a short course of
corticosteroids OR patient has an infection
! Add Glargine 10-12 units at breakfast in addition to maximum OHA to provide a
temporary ‘top up’ for a few days. (Dose may need adjustment based on
response).
! Cease this additional dose of insulin when no longer required and/or prior to
discharge.
! Avoid random short acting insulin (particularly overnight) in response to a single
high BGL unless patient is symptomatic as this is more likely to cause
hypoglycaemia.

16
Table 3
Table 4
Basal / bolus intensive insulin regimen:
This is an intensive four times a day insulin regimen using short acting insulin with
each main meal and long acting analogue insulin at bed time.
Initial Dose Calculation:
0.3 to 0.5 units/kg as a total daily dose divided over four doses a day
OR
the patient’s previous total daily insulin dose divided over four doses a day.
Use approximately 2/3 of the total daily dose evenly split into 3 bolus doses; 1/3 of total
daily dose as basal bedtime dose
eg. 60kg patient - Total daily insulin dose calculated as 0.5units/kg/day = 30 units.
Split doses as:
Breakfast 6 units NovoRapid
Lunch 6 units NovoRapid
Dinner 6 units NovoRapid
2100 12 units Glargine
OR
Patient previously on twice daily insulin of 40 units with breakfast and
25 units with dinner = 65 units daily.
Split doses as:
Breakfast 14 units NovoRapid
Lunch 14 units NovoRapid
Dinner 14 units NovoRapid
2100 24 units Glargine
Dose Adjustments:
Review patient’s 24 hour BGL profile each afternoon and adjust insulin orders
prospectively.
Adjust each dose up or down by 10% of current dose as required.
Current order Adjusted order
Breakfast 6 units NovoRapid 6 units NovoRapid
Lunch 6 units NovoRapid 5 units NovoRapid (decrease)
Dinner 6 units NovoRapid 6 units NovoRapid
2100 12 units Glargine 14 units Glargine (increase)
As the BGL at 0600 was high, the bedtime dose of Glargine is increased to prevent
the next morning’s reading from being high again. As the patient had hypoglycaemic
episode at 1600, the lunch time insulin dose is reduced to prevent a similar occurrence
the next day. The other two doses (breakfast and dinner) were left unchanged as the
blood glucose responses to them (at 1100 and 2100) were in the target range.
The recommendations of NovoRapid® has been made on the basis
of standardisation. Humalog® and Apidra® are considered clinically equivalent
and can be used as an alternative NovoRapid®.
Example: Based on 24 hour BGL profile: mmol/L
0600 1100 1600 2100
15.0 8.0 2.8 6.0

17
Table 4
Changing usual insulin regimen:
! Review patient’s blood glucose profile over 24 hours.
! Alter insulin dose to prevent prospective blood glucose rise or fall (eg. If the
before breakfast BGL is high then increase the bedtime basal insulin dose to
prevent the next morning reading being high).
! Alter doses by 10% of the current dose.
Table 5
Sliding scale insulin for patients who are fasting - Subcutaneous only
! To be used ONLY in patients that are nil orally or fasting post-operatively.
! Commence 5% glucose infusion.
! Check BGL 6 hourly (not QID: best timing is 0600, 1200, 1800, 2400hrs).
! Administer Actrapid subcutaneously 6 hourly based on the blood glucose level.
BGL (mmol/L) ACTRAPID insulin dose subcutaneous
0 - 5.0 No insulin
5.1 - 8.0 2 units
8.1 - 12.0 4 units
12.1 - 16.0 6 units
16.1 - 20.0 8 units
> 20.1 12 units and notify medical staff
! Review patient’s BGL daily and increase insulin doses by 1 unit at each level
of the sliding scale if target BGL not achieved.
! Recommence patient’s usual OHA or insulin regimen when oral intake is
adequate and regular.
(The doses above may be used to determine a single stat dose of insulin when that
is required).
The recommendations of NovoRapid® has been made on the basis
of standardisation. Humalog® and Apidra® are considered clinically equivalent
and can be used as an alternative NovoRapid®.

18
Managing acute complications
Further reading about hypoglycaemia, diabetic ketoacidosis and hyperglycaemic
hyperosmolar state can be found in Unstable diabetes – Section 11. The following
information focuses on managing these acute complications in a hospital setting or a
heath service.
Hypoglycaemia
A `hypo’ kit and the hypoglycaemia protocol should be assembled and placed in a
prominent position in every health service, ward or clinical area. The following is an
example of a hypo kit:
It is recommended that hospitals and health services make a decision about which
glucose drink and which biscuit option to have in their hypo kit. The protocol on the
next page can be accessed in electronic format from the authors to enable modification
for an individual service.
* Suitable alternatives (equivalent to 15 grams carbohydrate)
- Give 60 mls Carbotest or Glucosan (75gm carbohydrate in 300 mls) OR
- Give 100 mls Carbotest or Glucosan (50gm carbohydrate in 300 mls) OR
- Give 90mls Lucozade OR
- Give 150mls of Lemonade
!
Biscuit serve options
2 plain Milk Coffee, Arrowroot or similar
6 Jatz or 3 Sao
Hypoglycaemia Management Kit
Glucagon 1mg (IU) - eg GlucaGen Hypokit
Glucose Intravenous Infusion 25g in 50mL (50%)
1 roll of 2.5 cm micropore
1 x 20 mL syringe
1 x 21 G x ¾ inch winged infusion set
3 alcohol wipes
1 x InterLink vial access cannula
Glucose drink equal to 15g CHO*
50 mL measure cup
2 biscuit serves (15g each)!
Example

19
Figure 4
Treatment of Hypoglycaemia
For patients on insulin or oral hypoglycaemia agents.
Indications: Blood Glucose Level (BGL) less than 4.0mmol/L irrespective of symptoms.
* See previous page
#
See previous page
If symptomatic with BGL above 4mmol
! Re test after ensuring patients finger is clean (simple hand washing) and ensuring
quality control is up to date.
! Provide reassurance and ensure meal/snack is not delayed.
! If any concerns, treat as hypo.
Important points
! Document events and treatment given.
! Notify doctor.
! Observe pulse and blood pressure with event.
! Post glucagon – vomiting is not uncommon.
If patient is receiving naso-gastric enteral feeding
! Administer 100 ml Carbotest via naso-gastric / enteral tube as per B.
! Recommence feeds at usual regime as per B.
A Safe to Swallow
(i.e. awake and
co-operative)
Go to B $
Unsafe to swallow or Fasting
(i.e. drowsy and / or
uncooperative or dysphagic)
! Notify doctor immediately
! Give 1mg glucagon IM
! If glucagon therapy is
unsuccessful then doctor
must review and may give
IV glucose
When safe to swallow go to B $
Unconscious
! Place in coma position
! Notify doctor immediately
! Give 1mg glucagon IM
! Doctor MUST review and
may give 10 – 20ml IV
glucose 50%
When safe to swallow go to B $
B ! Give 90 ml of Lucozade (15g equivalent) (See previous page for options)*
! Give 2 biscuits (15g equivalent) (See previous page for options)
!
C ! Repeat BGL 15 minutes after initiation of treatment
! If BGL is less than 4.0mmol/L
! - If safe to swallow Repeat B !
- If unsafe to swallow Repeat A !
! If BGL greater than 4.0mmol/L AND symptoms are no longer present go to D$
D ! Repeat BGL in 1 hour
! If BGL is less than 4.0mmol/L OR patient has symptoms – Repeat B !
! If BGL is greater than 4.0mmol/L AND symptoms are no longer present
- Cease hypoglycaemia treatment
- Investigate cause
EXAMPLE

20
Length of observation
Be aware that the risk of having further hypoglycaemic events is increased in the hours
immediately following a hypo. For example older people on oral hypoglycaemic agents
(sulphonylureas) are at greater risk of recurrent hypoglycaemia and may need intravenous
infusions of dextrose 5%.
Patients should be monitored more closely for the next 12-24 hours. The BGL frequency
will depend on the severity of the hypo as well as the person’s individual risk factors. If
unsure, discuss with senior nursing staff or MO / GP. Observe person for at least 24
hours and blood glucose levels monitored 2 hourly if needed, up to 12-24 hours
depending on severity and duration of episode.
Document hypoglycaemic episode, action taken, outcome, monitoring progress and
possible cause.
Note: some form of fast acting, rapidly absorbed carbohydrate should be left with
the person.
Preventing hypoglycaemia
Identify Cause Education Staff Education
! missed / delayed meals /
snacks
! has vomited / insufficient
intake
! over medication
! increased activity
! weight loss without
medication
! possible self-induced
! excessive alcohol
! fasting for procedure
! if patient receiving enteral
feeding-tube blocked or
turned off
! extremes of weather
temperature
! check knowledge /
skills
! recognition
! treatment
! prevention
! medical alert
! to carry fast acting
CHO and has near
bedside
! appropriate meals
! appropriate snacks
! correct medication
! alert medical officer
of recurrent low
BGL’s
! accurate monitoring
results
! encourage patient to
report symptoms
! if patient receiving
enteral feeding,
consider IM glucagon
1mg prescribed as a
standing order
For further assistance and education contact diabetes educator or dietitians.

21
Diabetic ketoacidosis (DKA) and hyperglycaemic
hyperosmolar state (HHS)
The following information outlines the basic principles of managing diabetic ketoacidosis
(DKA) and hyperglycaemic hyperosmolar state (HHS) in hospital. For additional
information about DKA or HHS refer to Unstable diabetes – Section 11.
For specific clinical guidelines for hyperglycaemia in Country Health SA please refer to the
SA Rural and Remote Emergency Clinical Guidelines for Adults, 2007. The guidelines are
available from Country Health SA
We highly recommend you consult with a Diabetes Service experienced in managing
hyperglycaemic crises and ensure that there are local treatment protocols in place.
Diagnosis
The process of HHS usually evolves over several days or weeks, whereas the evolution of
an acute DKA episode is much shorter. HHS only occurs in type 2 diabetes. 6
DKA is
associated with type 1 diabetes but has been known to occur in people with type 2
diabetes in the presence of an acute event such as septicaemia, respiratory collapse,
myocardial infarction etc. 7
Clinical presentation
For both DKA and HHS the clinical picture consists usually of polyuria, polydipisa,
polyphagia, weight loss, vomiting, abdominal pain (only in DKA), dehydration, weakness,
altered level of consciousness or mental status, and finally coma. Other physical findings
may be poor skin turgor, Kussmaul respirations (in DKA), tachycardia, hypotension,
alteration in mental status, shock and ultimately coma (more common in HHS).6
Nursing considerations
! Capillary blood glucose
! Blood or urine ketones
! Baseline observations
! Prep for IV cannulation
! Cardiac monitor
! O2 saturation
! Start fluid balance
! Ice chips or oral fluids if tolerated
! Consider in-dwelling catheter
Laboratory tests
! plasma glucose
! blood urea nitrogen / creatinine
! serum ketones
! electrolytes (with calculated anion gap)
! osmolality
! urinalysis
! urine ketones by dipstick
! arterial blood gases
! complete blood count
! ECG
! Bacterial cultures if infection suspected

22
Treatment
Successful treatment of both DKA and HHS requires correction of:
! dehydration
! hyperglycaemia
! electrolyte imbalances, and
! the identification of co-morbid precipitating events and frequent patient monitoring is
crucial.
Fluid therapy
The initial fluid therapy is aimed at expansion of the intravascular volume and restoration
of renal perfusion. Subsequent choice for fluid replacement depends on the state of
hydration, serum electrolyte levels and urine output.6
Insulin therapy
Unless the DKA is mild, intravenous insulin infusion is required.
Potassium
Even though total body potassium may be depleted, mild to moderate hyperkalaemia is
not uncommon in patients with DKA or HHS. Insulin therapy, correction of acidosis, and
volume expansion decrease serum potassium concentration. Close monitoring of
potassium is needed to identify hypokalaemia. Replacement potassium may be needed.
Refer to your hospital clinical guidelines.
Bicarbonate
Severe acidosis in DKA can lead to a number of adverse vascular effects. The use of
bicarbonate in DKA will depend on the pH level.
Complications
The most common complications of DKA and HHS includes hypoglycaemia from over
administration of insulin, hypokalaemia due to insulin administration and treatment of
acidosis with bicarbonate and hyperglycaemia secondary to interruption / discontinuation
of IV insulin therapy without adequate cover from subcutaneous insulin. Cerebral oedema
is rare but when it occurs it is frequently fatal.6

23
Insulin pumps in an inpatient setting
Insulin pump therapy during an inpatient stay is possible as long as the person (or a
parent or spouse) and the endocrinologist are consulted and nursing staff are confident to
supervise and document the treatment. Hospital staff are not expected to be experts in
insulin pump therapy. It is important to seek assistance from the diabetes team who is
managing the persons pump therapy. It is essential that contact be made with the
person’s endocrinologist and / or their diabetes educator to develop a plan for the persons
admission and discharge. See Medication – Section 10 for background information about
insulin pump therapy.
If the person is unable to self manage the pump (eg simply too unwell, in pain, impaired
cognition or conscious state) it is recommended that the insulin pump is stopped and
replaced by an insulin infusion. The pump should not be removed until there is
another method of insulin replacement eg insulin infusion. If an insulin infusion is not
possible then multiple insulin injections will be required (long acting and short acting
insulin). Transition insulin dosing must be discussed with the patient’s endocrinologist.
If a patient is self managing the pump it is essential that nurses oversee and record blood
glucose results, insulin doses and carbohydrate (CHO) intake. This includes checking the
bolus doses with the patient before it is administered. Ensure accurate documentation at
all times.
In a hospital setting the pump should not be turned off unless:
! For the treatment of severe hypoglycaemia (less than 2mmol/L). Following
treatment for hypoglycaemia and return to target blood glucose levels, the insulin
pump must be re-commenced.
! Showering and person is not hyperglycaemic. Ensure pump is turned back on
within 60 minutes.
Patient needs to be able to fully self manage the insulin pump
OR
MO needs to order alternative treatment if patient unable to self manage
the pump

24
Management of the insulin pump and procedures
! The person should have recent information from their last endocrinologist visit
stating the person’s usual basal rates etc.
! The surgeon or medical practitioner should contact the person’s endocrinologist well
prior to the procedure to get specific advice regarding management of insulin.
! The insulin pump should not be worn during an X-ray, CT or MRI.
! Ensure a detailed admission and discharge plan is put in place. Contact the
person’s diabetes educator or endocrinologist to develop this. They will give advice
about the management of diabetes during planned procedures. If the procedure is
unplanned (trauma, medical emergency) stop the pump and commence an insulin
infusion.
! If the person is having a general anaesthetic, the insulin pump must be
disconnected / removed and insulin must be administered via insulin infusion or
subcutaneous insulin injections.
! If the person is having a local anaesthetic an assessment of the persons ability to
self manage pre, during and post the procedure must be considered.
! Ensure a new line is put in place the day before the procedure (not the morning of
the procedure).
! Ensure cartridge volume is enough to carry the person through to a suitable time
frame (eg will not run out in the middle of the night).
! In case of pump failure or other emergency obtain contact phone numbers from the
patient including endocrinologist, family member, pump support person, pump
manufacturer. It is also important to write down any instructions that the patient has
been given regarding insulin doses should pump failure occur.
Caring for the insertion site and line change
To reduce the risk of infection and ensure line patency:
! Change the infusion line and site every three days.
! Ensure thorough handwashing before procedure.
! Protect the infusion line from contamination when disconnected.
! Some health services recommend the use of an anti-bacterial agent such as Solu-I-
V or Persist Plus to clean the area prior to insertion of the cannula.
! Document date and time of insertion site and line change in the case notes.
Potential problems to look for
! Subcutaneous site eg infection, allergies, tunnelling.
! Line kinks, leaks, clogs.
! Pump may have mechanical problems.
! There is an accelerated tendency for diabetic ketoacidosis (this can occur within
3-6 hours of ceasing the pump as the insulin supply stops).

Diabetes Manual_ a Guide to Diabetes Management.pdf

Diabetes Manual_ a Guide to Diabetes Management.pdf

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