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Коморбідний ендокринологічний пацієнт

Международный эндокринологический журнал Том 19, №7, 2023

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Сестринський догляд за хворими на цукровий діабет

Сестринський догляд за хворими на цукровий діабет

Авторы: K.S. Salihu
Mental Health Center, AAB College, Pristina, Kosovo

Рубрики: Эндокринология

Разделы: Клинические исследования

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Резюме

Актуальність. У зв’язку зі зростанням кількості хворих на цукровий діабет у всьому світі медсестри всіх спеціальностей і посад все частіше доглядають за цими людьми щодня. Мета цього дослідження полягала в тому, щоб вивчити останні рекомендації та окремі дослідження з лікування цукрового діабету та визначити місце медичних сестер у мультидисциплінарній команді. Матеріали та методи. У статті використано дескриптивні методи та методи порівняльного аналізу для визначення особливостей медсестринської практики у веденні хворих на цукровий діабет. Результати. З вивченої інформації стало зрозуміло, що медичні сестри повинні бути готові отримати якісну освіту, пов’язану з постійною підтримкою та доглядом у громаді, у закладах первинної медичної допомоги або в лікарнях для таких пацієнтів. Навчання самоуправлінню та розв’язанню психосоціальних проблем є ключовим елементом догляду, зокрема, за хворими на діабет. Програма навчання та підтримки самоконтролю хворих на цукровий діабет є важливим інструментом для спілкування між пацієнтом і медсестрою, включно з постійною психологічною підтримкою за допомогою освітніх методів для розв’язання питань і проблем, які виникають у людей з діабетом та їхніх сімей. Висновки. Підготовлені медсестри також можуть проводити скринінг психічних розладів і ускладнень цукрового діабету з метою своєчасної діагностики або запобігання їх розвитку. Незалежно від нових технологій чи методів лікування медсестри ніколи не повинні втрачати свою роль захисників прав пацієнтів.

Background. Due to the global rise in diabetes patients, nurses of all specialties and positions are increasingly caring for these individuals on a daily basis. The purpose of this study was to examine the latest re­commendations and individual studies on diabetes management and to determine the place of nurses in a multidisciplinary team. Materials and methods. The article used descriptive methods and methods of comparative analysis to determine the characteristics of nursing practice in the management of patients with diabetes. Results. From the information studied, it became clear that nurses should be prepared to receive quality education associated with ongoing support and care in the community, primary health care institutions or in hospitals for such patients. Education in self-management and psychosocial problem solving are key elements of diabetes care and nursing. The Diabetes Self-Management Education and Support program is a crucial tool for patient-nurse communication, involving ongoing psychological support through educational techniques to address questions and concerns from individuals with diabetes and their families. Conclusions. Trained nurses can also perform screening for mental disorders and diabetes complications in order to timely diagnose or prevent their development. Regardless of new technologies or treatments, nurses must never lose their role as advocates for patients’ rights.


Ключевые слова

мультидисциплінарна команда; самоконтроль; скринінг; лікувальне харчування; фізична активність

multidisciplinary team; self-management; screening; medical nutrition therapy; physical activity

doi: http://dx.doi.org/10.22141/2224-0721.19.7.2023.1324

Introduction

Updated standards for the management of people with diabetes encourage the creation of a multidisciplinary team consisting of mental health professionals, psychologists, nutritionists, physicians, pharmacists and nurses, with the latter playing a critical role in monitoring, educating and supporting patients and their significant ones [1]. According to the International Diabetes Federation [2] about 537 million people suffer from diabetes, about 75 % of which are concentrated in low- and middle-income countries, and about 6.7 million deaths per year are directly related to this disease or its complications. Data are also presented that 541 million people have impaired glucose tolerance (prediabetes), which is a potential source of new patients with diabetes type 2. Meanwhile, the Centers for Disease Control and Prevention in America reports 30.3 million cases of diabetes as of 2020, of which 7.1 million (almost a third part) are undiagnosed or underdiagnosed, and an additional 84.1 million Americans have prediabetes [3]. Thus, it is clearly observed that the trend of increasing cases of diabetes, mortality due to diabetes and its complications has already been more than confirmed.
X. Lin et al. [4] reported a prognostic worsening of the burden of diabetes in both global and regional populations adjusted for morbidity, mortality and disability-adjusted life-years (DALYs), and the World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases in 2025 was developed. Also, nume–rous diabetes associations around the world regularly publish improved standards of patient care, providing effective re–commendations for multidisciplinary treatment of this target group [5, 6]. Diabetes causes a tremendous burden on the health care system, especially on the primary health care, which requires nursing staff in accordance with Dorothea Orem’s Self-Care Theory to educate patients to manage their own well-being and symptoms on their own, since they cannot be constantly monitored medical wor–kers, unless the clinical situation requires otherwise [7]. According to J.Y.C. Yip [8] such training consists of applying practical nursing knowledge by determining how the patient can best perform self-care given their living conditions and the availability of assistive devices, and it enables the identification and use of sensitive indicators when glycaemic control, for example, blood glucose. However, such theory has both strengths and limitations in primary care settings: F.R.D.M. Marques et al. [9] draw attention to the fact that the development of the disease and the consequences of chronic hyperglycaemia may be poorly recognized by the elderly, which hinders adherence to self-care practices and disease control.
According to J. Lawler et al. [10] diabetic nurses are essential for diabetes management, especially in the hospital setting, as their intervention enhances the patient experience and improves outcomes. At the same time Y. Wang et al. [11] attract attention, that non-endocrinology nurses do not have sufficient knowledge of diabetes and are in dire need of training to provide quality patient care. Because diabetes is a multifaceted pathology, often with unaccounted for or misdiagnosed symptoms, nurses must offer educational and support services as the patient’s first point of contact with the health care network. The purpose of this article is to review existing guidelines and research to build understanding and highlight key principles in the nursing practice of diabetes management. This study may be useful for policy development, priority setting, and resource allocation for diabetes nursing strategies.

Materials and methods

The screening and selection of data was provided among review articles and published studies in the MEDLINE, PubMed and Scopus databases. The search was conducted using the queries “nursing care diabetes”, “diabetes nursing”, “diabetes mellitus management”, “diabetes mellitus recommendations”. The search was carried out using the filtering of articles within the boundaries from January 1, 2020 to June 15, 2023. From the results of the query, the first 100 proposed positions were studied, as well as 10 each for queries specifying “diabetes gestational”, “diabetes criteria”, “diabetes self-care”, “diabetes treatment”, “diabetes diagnostics”. Other studies were obtained using academic search engines available via Google, or from the reference lists of review articles. Certain articles did not fit into the specified time frame, but it was decided to include them in the survey, since their data resonated with the data from the initially filtered articles, which was confirmed by them and the continuance of the researched topics. The following were selected as inclusion criteria for the review: review and comparative articles; local (within the medical institution or city/region) statistical studies; recommendations of diabetes associations of the last 5 years; all studies evaluated patients with type 1 and type 2 diabetes; research should address the following topics: current practices, principles, and research in diabetes management nursing practice; statistical data must cover the period within the last 5 years. 
The following exclusion criteria were chosen from the review: incomplete research reports or parts of research; unpublished results of research; repeated publications by authors (except diabetes associations); research in the context of diabetes, but without reference to the role of nursing practice. According to the inclusion and exclusion criteria, 68 articles were selected for the review. Data extraction included the name of the first named author or all authors (if their number did not exceed the co-authorship of 3 researchers), characteristics of the study (type and purpose of the study, year of publication) and measured outcomes (for example, indicators of specific and general morbidity, mortality, level of glycosylated haemoglobin, fasting and postprandial glucose). The article used descriptive methods and methods of comparative analysis, which were used to search for and determine the characteristics of nursing practice in the management of patients with diabetes, the share and role of nursing in a multidisciplinary team, current trends and the establishment of relationships in the doctor-nurse-patient system, ways to control glycemia, as well as determining the prospects for further research.

Results and discussion

One of the most significant changes that has occurred in the care of patients with diabetes is personalized treatment and education that listens to the most detailed requirements of each patient, including treatment adherence, comorbidi–ties, and prognosis. Since diabetes is considered a chro–nic disease, with the aim of a more qualitative approach to treatment, the six-component The Chronic Care Model was proposed, where such treatment goals as glycated hemoglobin (HbA1C) level, weight control, maintenance of physical activity, as well as discussion of possible alternatives to achieve these goals, which are implemented in cooperation with the patient and their family members, always taking into account their social class, financial capacity, quality of nutrition, possible language barriers, material resources. Such a model requires the active participation of the patient in the process of treatment, and in order to evaluate the quality of the provision of medical services and receive feedback, nurses can use the Patient Assessment of Chronic Illness Care (PACIC) scale after 6 months of therapy, and this scale has received positive reactions from various scientists, and it is also translated into different languages, which only increases its accessibility for patients. An example of several questions, as well as the source of this questionnaire, is presented in Fig. 1. Since the main tool of interaction between the patient and the nurse is a conversation, the worker can get basic information about age, education, work and study status, housing si–tuation, the patient’s perception of their own health, support elements, eating habits and physi–cal activity, socialization, national, cultural and religious characteristics, complications and duration of the disease, concomitant diseases and health priorities.
In this way, having an active conversation can be used by both parts of newly formed system, both patient and nurse, to develop effective support strategies for a person with diabetes: for example, a man with a low financial income can choose to eat home-cooked meals during the day instead of buying ready-made meals, saving and while maintaining health; and a woman who has lost a partner may choose to become part of a diabetes support group, be active in the community, and lead an active social life. The criteria for the diagnosis of diabetes mellitus remain the same as the classic ones: fasting glucose level, blood glucose level 2 hours after a 75-gram oral glucose tolerance test (OGTT) and HbA1C level are key for diagnosis [13]. However, it is worth noting that the latter is not recommended as a diagnostic me–thod in patients with a violation of the number of circulating erythrocytes, for exam–ple, with polycythaemia, haemolytic anaemia, pregnancy in the II–III trimester or with chronic kidney disease that requires replacement therapy (dialysis) — for such patients only glucose is used as a diagnostic criterion. Laboratory criteria for the diagnosis of prediabetes and diabetes are presented in Table 1 with reference limits in different measurement units.
It is also worth noting that the diagnostic criteria for diabetes include classic symptoms of hyperglycaemia (polyuria, thirst, dry and itchy skin, changes in body weight, appetite), hyperglycaemic crisis, randomly recorded plasma glucose level ≥ 200 mg/dL (≥ 11.1 mmol/l). However, considering that both diabetes and prediabetes have a long asymptoma–tic period or few symptoms, nurses can help these patients by pre-assessing their risk using a questionnaire such as the American Diabetes Association Risk Test for Diabetes, which is currently available in English and Spanish. This test asses–ses diabetes risk based on age, gender, heredity, comorbidities (such as hypertension), physical activity, ethnicity, weight and height. Further screening is recommended for all obese adults, adults over 45 years of age, and current guidelines re–commend screening for children and adolescents or those with more than 2 risk factors for type 2 diabetes. These risk factors include: family history of diabetes (first-degree rela–tives: mother, father, siblings), overweight or obesity according to the Quetelet index/body mass index (BMI), age 45 years or older, ethnicity (black, Alaska Native, Native American, Asian, Hispanic, Indigenous Oceania), history of hypertension and dyslipidaemia (low serum high-density lipoprotein cholesterol and/or high triglycerides and low-density lipoprotein cholesterol), history of gestational diabetes or birth weight ≥ 9 lb (≥ 4000 g), low physical activity, history of cardiovascular disease or acute cerebrovascular disorder, history of depression, history of polycystic ovaries [13]. Patients with diabetes have a high risk of developing cardiovascular diseases, which is confirmed by individual studies and global organizations such as the American Heart Association [14]. For this reason, patients with diabetes should be included in well-designed counselling and support programs and should be screened and consulted for possible modifiable factors associated with cardiovascular disease.
Nutritional assessment and recommendations for healthy eating, weight management, physical activity, and psychosocial needs are important elements that should be provided by nurses at each stage of treatment. Personalized diabetes prevention programs, education programs, and support programs for self-management of diabetes, as well as programs designed to emphasize weight loss (7 % of recommended body weight) and exercise recommendations (150 minutes per week of moderate intensity) are considered important pillars for effective control of diabetes and pre-diabetes [12]. Currently, there is no specific diet to protect against diabetes, although weight loss is important and even key in the treatment of type 2 diabetes. Dietary regimens rich in saturated and unsaturated fats (such as the Mediterranean diet) have been shown to help better control diabetes. A healthy diet that includes whole grains, nuts, dairy products, berries, and limiting red meat, added sugar, and sugary beverages may also be beneficial. Moderate exercise, such as brisk walking, can improve insulin sensitivity and reduce abdominal fat accumulation. Modest but sustained weight loss has been shown to be effective in glycaemic control by reducing the use of oral antidiabetic agents, and such improvement occurs mostly in the early stages, when insulin secretory capacity is not yet too impaired.
Both drug treatment and patient-specific factors are considered and discussed during shared decision-making between the nurse and the patient. These factors include efficacy, risk of hypoglycaemia, renal effects, weight changes, cardiovascular risks, cost of treatment, and route of administration. Drug therapy is usually carried out with one drug, usually metformin. Other injectable or non-injectable treatment methods are added to control possible cardiovascular complications — in this category of patients, the addition of agents that reduce cardiovascular risks (such as empagliflozin) is recommended, and liraglutide can be considered for patients with a BMI > 27 kg/m2 to prevent obesity and reduce cardiovascular risks. But at the same time, there is a problem with the financial capabilities of patients, because combined therapy can carry a financial burden during treatment, and according to G. Sa–theesh et al. [15], the price of drugs can reduce the patient’s adherence to therapy, so the nurse aims to encourage the patient to compliance with all appointments, or to discuss with the doctor alternatives to reduce the cost of therapy. According to the latest recommendations, the level of glycemia should be controlled at the following level: pre-meal glucose 80–130 mg/dl (4.4–7.2 mmol/l) in capillary blood, postprandial blood plasma glucose < 180 mg/dl (< 10 mmol/l). Diabetes management is based on different steps because of the progressive nature of disease, starting with appropriate lifestyle intervention, including referral to special programs such as Diabetes Self-Management Education and Support (DSMES) [16]. Patients with diabetes, without exception, should be referred to DSMES, Medical Nutrition Therapy (MNT) and conti–nuously eva–luated for diet, psychosocial status and emotional support of various types. Recent studies support the creation of small virtual groups through which patients and nurses can build communication by discussing treatment and well-being concerns or using digital tools for telemonitoring of diabetes, which is supported by the Ame–rican Association of Clinical Endocrinology, but as noted by L. Blonde et al. [5] and G. Grunberger et al. [17], the use of telecommunication devices may be limited in older patients, which also requires training from nurses.
DSMES can be offered in groups or individually, as well as via virtual assistance. Regardless of the format, it should be patient-centred, cover clinical and psycho-emotional aspects, and be tailored to the specifics of each patient — meaning that care and education would be more effective if nurses used patient-centred communication alternatives (such as open-ended questions, active listening, setting independent goals and psycho-emotional assessment). For example, one might first ask the patient about the challenges they face in managing their diabetes, what questions they have, and these are ways to assess their needs and perceptions of their disease so they can be addressed first at DSMES or at their next doctor’s visit. Standards of care should be aimed, for example, at the correct solution of problems of the psychosocial spectrum in order to change the behaviour that affects the quality of life and worsening of the patient’s symptoms. Patients are encouraged to be monitored for symptoms of depression, anxiety, or cognitive spectrum disorders and nurses can use questionnaires to screen for mental disorders among their patients. Since this is a common phenomenon and directly related to the way of life, the solution to the problems of the psychosocial spectrum should be correct and effective not only for the patient, but also for family members — the prevalence of problems of this nature is from 18 to 45 %, with a frequency of 38 to 48 % within the first 18 months of diagnosis. According to L. Fisher et al. [18] high levels of distress (feelings of guilt, anger, frustration, fear) correlate with elevated HbA1C levels, low self-esteem, and nonadherence to diet, exercise, or treatment regimens. Management of obesity in patients with type 2 diabetes is an important part of diabetes management. Table 2 presents the classification of body weight according to body mass index taking into account ethnic characteristics, according to World Health Organization.
Bariatric surgery is a possible alternative for the category of diabetic patients with a BMI of 35 kg/m2 or more — in many studies it was found that the intervention led to the normalization of glucose levels. Regarding diabetes and pregnancy, an important recommendation for nurses is to ensure counselling is provided before conception and at each stage of pregnancy to women of reproductive age — areas to focus on are family planning, maintaining HbA1C < 6.5 % before pregnancy. According to the latest American Diabetes Association guidelines, glucose targets are a fas–ting plasma glucose level of < 95 mg/dL (5.3 mmol/L) and a 1-hour postprandial glucose level of < 140 mg/dL (7.8 mmol/L) or a 2-hour postprandial glucose level < 120 mg/dL (6.7 mmol/L). In general, the haemoglobin A1C target during pregnancy is < 6 % (42 mmol/l) if this can be achieved –without significant hypoglycaemia, but the target can be lowered to < 7 % (53 mmol/l) if necessary to prevent hypoglycaemia, because according to N. Mohan and A. Banerjee [20], pregnant women are more prone to metabolic risks, so they should be informed about the symptoms of hypo- and hyperglycaemia. Insulin is the preferred treatment for diabetes type 1 and type 2 during pregnancy, so the woman should be trained in injection techniques, although oral metformin is a possible alternative with its own advantages and disadvantages. In this category of patients with diabetes, it is no less important to monitor the appearance of possible complications and their treatment. A very important element is the use of low maintenance doses of aspirin to prevent preeclampsia, starting from the 20th week of gestation until the birth of the child. In pregnant patients with diabetes and chronic hypertension, the target blood pressure is 110–135/85 mm Hg, so the woman should be informed about the importance of antihypertensive therapy. It is also worth noting that potentially harmful drugs during pregnancy (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins) should be stopped after conception and avoided in sexually active women of childbearing age who are not using reliable contraception, so this issue also requires detailed discussion.
Regarding the issue of cardiovascular complications, the prevention and treatment of remote complications of dia–betes remains the main task of the medical staff treating this category of patients. Lifestyle adaptation, statin the–rapy is recommended for patients older than 40 years even without coronary heart disease, but lifestyle changes and glycaemic control are strongly recommended for patients with dyslipidaemia. Smoking cessation is an important goal in lifestyle modification, and B. Daly et al. [21] emphasize the importance of nurse-patient communication. Optimi–zing glucose and blood pressure is of particular importance in reducing the risk of progression of kidney disease and retinopathy. Research by S. Atkinson-Briggs et al. [22] and D.C. Goncalves-Bradley et al. [23] demonstrated the benefit of nurse-administered retinopathy screening, as it reduced physician appointment times and increased case detection rates. Diabetic foot is one of the important complications of diabetes. D.R. Hughes et al. [24] demonstrated that nurse-led patient education focusing on diabetic foot care is feasible and has the potential to improve diabetes knowledge and self-care, which are precursors to preventing debilitating foot complications. Patients should be informed about the critical situations of uncontrolled glycaemia that can happen to them and be taught the algorithms of action, and in turn nurses should be educated on this issue, especially with regard to patients with low adherence to control, children with diabetes type 1 and their parents. For example, a blood level that is considered hypoglycaemia is less than 70 mg/dL (3.9 mmol/L), and the nurse may recommend taking 15 to 20 g of fast-acting glucose (glucose tablets or a sweet sandwich), and after the level normalizes glucose in the blood, you can eat light food, in the worst case — immediate hospitalization. Patients may be asked to use tools that identify them as having diabetes and to carry devices to check their current glucose levels (glucometers). Patients should also be aware that illness or other stressful events can raise glucose levels and lead to diabetic ketoacidosis in patients with type 1 diabetes or a hyperosmolar hyperglycaemic state in patients with type 2 diabetes — nurses and physicians should educate patients about the symptoms of ketoacidosis and emphasize the need to receive recommended vaccinations, T.R. Anis et al. [25], B. Joob and V. Wiwanitkit [26] emphasize the importance of receiving vaccination against coronavirus infection according to current epidemic situation.
At the hospital stage, nursing therapy is based on discharge planning, ensuring balanced treatment, care in the transition period, proper communication with the patient and family members — along with the reference to DSMES and MNT, nurses need to emphasize the importance of blood glucose monitoring, information, treatment and prevention of hypoglycaemic events, hyperglycaemic events, continued medication use, and the importance of nutrition [27–29]. As for special populations, nurses, parents, and other health professionals should prepare kids with diabetes for the transition to health care and self-management in adulthood [30, 31]. Thus, self-management education and psychosocial problem solving are critical elements of both diabetes ma–nagement and nursing practice [32]. Nurses can use quali–ty tools to monitor the physical and mental condition of patients, and their role remains indispensable and no less important than the work of the attending physician. But it is worth noting that most modern resources (questionnaires, applications) are available in a limited number of languages (mainly English), which can create a restriction in their use for users from different countries, and in the future, they require high-quality translation and testing with feedback from patients and medical staff who used them.

Conclusions

Regardless of their speciality or position, the majority of nurses deal daily with patients who have diabetes because of the rising number of diabetic patients around the world (especially in low- and middle-income countries). According to the most recent guidelines and individual studies on diabetes management the role of nurses in a multidisciplinary team is still important. The evidence gathered made it clear that nurses need to be ready to obtain high-quality training linked with ongoing assistance and care for patients of different age and social status. Key components of diabetes treatment and nursing include education in self-management and psychosocial problem solving. A crucial tool for patient-nurse communication is the DSMES program. In order to quickly diagnose or stop the onset of mental problems and diabetic complications (diabetic foot and retinopathy), trained nurses can also do screening for these conditions. Nurses need to be alert to obesity and cardiovascular risks. Patients should be informed about the priorities of a healthy lifestyle, quality nutrition (especially the Mediterranean diet), smoking cessation, and regular medication intake. Discussing pricing and material options can have a significant impact on patient adherence to treatment. Communication between a nurse and a patient can take place both in a medical institution and at the patient’s home, as well as online through special applications or social groups. Modern tools for diabetes management and communication should be publicly available to users from all over the world, so in the future they should be adapted and researched on their quality and compliance with local characteristics (ethnic, religious).
 
Received 18.09.2023
Revised 02.11.2023
Accepted 05.11.2023

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