Diabetes in Hospital Diabetes in Hospital: A Practical Approach for Healthcare Professionals Paula Holt © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-72354-8 For Ian, Matthew and Jonathan Diabetes in Hospital A Practical Approach for Healthcare Professionals Paula Holt A John Wiley & Sons, Ltd., Publication This edition fi rst published 2009 © 2009 John Wiley & Sons, Ltd Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientifi c, Technical and Medical business with Blackwell Publishing. Registered offi ce John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom Editorial offi ce John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell. 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This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Holt, Paula, 1963– Diabetes in hospital : a practical approach for healthcare professionals / Paula Holt. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-72354-8 (pbk. : alk. paper) 1. Diabetes–Patients–Hospital care. I. Title. [DNLM: 1. Diabetes Mellitus–therapy. 2. Hospitalization. WK 815 H758d 2009] RC660.7.H65 2009 616.4′6206–dc22 2008041816 A catalogue record for this book is available from the British Library. Set in 10/12pt Sabon by SNP Best-set Typesetter Ltd, Hong Kong Printed in Singapore by Fabulous Printers Pte Ltd 1 2009 Contents Preface viii Acknowledgements x List of abbreviations xi 1 Understanding diabetes 1 Aims of the chapter 1 What is diabetes? 1 History of diabetes and insulin 2 Anatomy and physiology in the absence of diabetes 3 Insulin 4 Glucagon 8 Classifi cation of diabetes 9 Type 1 diabetes 11 Type 2 diabetes 14 Signs and symptoms of diabetes 20 Making a diagnosis 22 Conclusion 23 2 Treating diabetes effectively 24 Aims of the chapter 24 Insulin therapy 25 Case study: Charlotte 36 Case study: David 48 Conclusion 49 Further information 50 v vi Contents 3 M anagement and treatment of acute diabetes complications in Accident and Emergency 51 Aims of the chapter 51 Hyperglycaemia and diabetic ketoacidosis 51 Case study: Pippa 54 Hypoglycaemia 61 Case study: Jerry 63 Conclusion 70 4 Diabetes in the medical ward 71 Aims of the chapter 71 Diabetic neuropathy 71 Peripheral vascular disease 75 Treatment of neuropathic foot ulcers 77 Case study: Malcolm 80 Conclusion 91 5 Diabetes and the surgical patient 93 Aims of the chapter 93 Risk of surgery 94 Case study: Julie 95 Surgery in different types of diabetes 110 Conclusion 113 6 Diabetes in coronary care 115 Aims of the chapter 115 Metabolic syndrome 116 Central obesity 118 Infl ammatory defects 120 Dyslipidaemia 120 Hyperglycaemia 121 Case study: Maggie 122 Conclusion 134 7 Management of diabetes in the renal unit 135 Aims of the chapter 135 Anatomy and physiology of the normal functioning kidney 136 Diabetic nephropathy 139 Diabetic nephropathy and cardiovascular disease 142 Hypertension 143 Case study: Winston 144 Conclusion 155 Contents vii 8 Diabetes and liver disease 156 Aims of the chapter 156 Alcohol-related liver disease 157 Non-alcoholic fatty liver disease 158 Non-alcoholic steatohepatitis 158 Treatment of non-alcoholic fatty liver disease 159 Hepatitis C 163 Hereditary haemochromatosis 163 Case study: Paul 166 New-onset diabetes following transplantation 170 Conclusion 172 9 Discharging the patient with diabetes from hospital 173 Aims of the chapter 173 National Service Framework 175 Structured education 182 National programmes 184 Information prescription 188 Checklist for discharging the person with diabetes from hospital 191 Conclusion 191 References 192 Index 207 Preface Today people are busier than ever but have more sedentary lifestyles. This, coupled with the increased abundance and availability of convenience foods, is contribut- ing to rocketing levels of obesity. With this comes increasing numbers of people developing type 2 diabetes. As type 1 and type 2 diabetes transcend almost every system in the body, this will have a huge impact on health service delivery and will undoubtedly lead to more diabetes-related hospital admissions. The aim of this book is to provide healthcare professionals with the knowledge and skills to be able to care effectively for these people during their time as a hospital in-patient. It considers the different types of specialist area a person with complications of diabetes may be admitted to, and goes on to discuss the care relevant to that person in that particular specialist setting. The application of theory to practice is achieved through the use of different case studies to which an evidence-based, problem-solving approach is applied. The need for ‘joined up’, multidisciplinary working while considering fully the bio-psycho-social needs of the patient is emphasized. The contents of the book are not ‘profession specifi c’ and readily relate to all members of the multidisciplinary team who are responsible for the care of the person with diabetes. It is aimed at providing help and guidance to those who do not have specialist knowledge of diabetes but believe their care of patients with diabetes could be improved. The advice and guidance offered is presented in a clear and logical way with evidence-based rationales so that the healthcare prac- titioner understands why they should be delivering the care in such a way. While is it recognized that there will be an overlap of care in different care settings, the main complication for that specialism is dealt with in the appropriate chapter. The fi rst two chapters of the book provide the reader with the conceptual hooks that are required to understand the principles of diabetes, maintaining and achieving blood glucose control and the effective treatment of diabetes. From this, viii Preface ix subsequent chapters focus on caring for the person with diabetes in different hospital settings and specialisms. Within each chapter, different aspects of diabe- tes care and complications are highlighted. Thus, the reader is able to ‘dip in and out’ of the chapters relating to their specialism, but if the book is read as a whole a complete picture of diabetes care is provided. Evidence-based rationales for care are provided, drawing upon key research fi ndings, National Institute for Health and Clinical Excellence (NICE) guidelines and the diabetes National Service Framework (NSF). A practical and logical approach is adopted with key points highlighted in boxes throughout, and at the end of each chapter. Diagrams are used to help illustrate key points. Paula Holt August 2008 Acknowledgements In compiling this book I acknowledge and thank a number of people for their help, support and encouragement: Alison Ketchell for her help with the cardiovascular implications related to diabetes and our in-depth discussions in the offi ce about the underlying pathophysiology. Mark Bevan and Diane Butler for their clear explanations, practical advice and support on the complexities of diabetic nephropathy and renal dialysis. Michelle Clayton for helping me understand the role of the liver and working with me to produce articles focusing on new-onset diabetes after transplantation and hereditary haemochromatosis. The knowledge gained from these, and our discussions over coffee, have been invaluable for the book. Janet Carling and Laura Dinning for their unconditional friendship; for facili- tating clinical practice for me; and for enabling me to manage and deliver patient care, from which I have learnt a great deal. All the people with diabetes with whom I have come into contact, including my dad, who have enriched my knowledge of diabetes and have provided me with some challenging situations to problem-solve and learn from. Finally, my students at all academic levels, who bring to the classroom an array of experiences and clinical situations that have been drawn upon in writing this book. x