A nursing portfolio structured with 4 learning needs about the diabetes management. A part of assessment for a health short course in diabetes

1. 1
Faculty of Health and Social Sciences
Unit Name: Understanding Diabetes
PORTFOLIO
May 2016

2. 2
FIRST LEARNING NEED
TO BE ABLE TO IDENTIFY A HYPOGLYCAEMIC EPISODE
Action Plan:
 Online research in EBSCO website with relevant and updated articles;
 Read updated literature and the latest guidelines;
 Complete an online e-learning Hypo Training Program, developed by
Diabetes.co.uk (see Appendix I);
 Observe and analyse clinical cases in the workplace environment.
Discussion:
Diabetes is a chronic disease related to the regulation of insulin by the
pancreas. The insulin, which controls the blood glucose level in all human body,
is produced insufficiently, causing hyperglycaemias (NICE, 2015b). The
management of diabetes is mainly concretized with regular exercise, healthy diet
and anti-diabetic medication. However, an inadequate treatment can increase the
probability of hypoglycaemias (NICE, 2015b).
Hypoglycaemia is defined by a blood glucose level below 4mmol/L (Joint
British Diabetes Society, 2013). It results from an inappropriate balance between
the amount of glucose taken, the glucose used and the level of insulin in the blood
(Joint British Diabetes Society, 2013; The Endocrine Society, 2009). For
instance, an insufficient consumption of food, mainly carbohydrates, or excessive
hours without any intake, can cause a lack of glucose in the blood, inducing a
hypoglycaemic episode (Joint British Diabetes Society, 2013). The increase of
exercise patterns, or the practice of moderate and intense physical activities can
also increase the recurrence of hypoglycaemias (The Endocrine Society, 2009).
People who are insulin-dependent have an increased risk to develop
hypoglycaemias (Joint British Diabetes Society, 2013). The insulin therapy
involves regular self-injecting daily doses, which require adjustments according
to the level of exercise or the type and quantity of food taken by the person with
diabetes (NICE, 2015b). Obviously, all of this process requires a confident and
structured self-management by the diabetic person, in order to prevent
complications, such as hypoglycaemias. Also, the use of sulfonylureas can easily

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cause hypoglycaemias in order to stimulate the insulin secretion (British National
Formulary, 2016).
There are more risk factors which increase the probability of a
hypoglycaemic event, such as: previous history of severe hypoglycaemias, poor
injection technique, renal impairment and lack of appropriate knowledge and
skills of self-management of diabetes (Joint British Diabetes Society, 2013; NICE,
2015b). Hypoglycaemias are more frequent in type 1 diabetes and elderly people
are more susceptible to develop it (Joint British Diabetes Society, 2013; The
Endocrine Society, 2009).
The longer duration of diabetes increases the occurrence of
hypoglycaemias as well (Joint British Diabetes Society, 2013). This is confirmed
by Olsen (et al., 2014), that affirmed that the perception of hypoglycaemic
episodes decreases with the progressive duration of diabetes, developing the
clinical syndrome of impaired awareness of hypoglycaemia. This syndrome
affects one in five adults with type 1 diabetes and it increases in twice the
frequency of mild hypoglycaemia, and up to six-fold the incidence of severe
hypoglycaemia (Schopman et al., 2010; Rogers et al., 2011; The Endocrine
Society, 2009). A study developed by Schoman (et al., 2010) related that the
patients with impaired awareness of hypoglycaemia have a much greater
exposure to lower blood glucose levels and to an increased incidence of
asymptomatic hypoglycaemia.
Therefore, the identification of the different symptoms of hypoglycaemia is
imperial to proceed with an effective treatment. They are divided in
neuroglycopenic, autonomic, and non-specific symptoms (Olsen et al., 2014;
Joint British Diabetes Society, 2013). The neuroglycopenic symptoms are a
consequence of a cerebral dysfunction due to a deprivation of glucose in the brain
cells (Olsen et al., 2014; Joint British Diabetes Society, 2013). Confusion,
drowsiness, odd behaviour, speech difficulty and poor balance characterise the
neuroglycopenic symptoms (Joint British Diabetes Society, 2013).
The autonomic symptoms are related to the sympathoadrenal activation,
causing sweating, palpitations, shaking and hunger (Joint British Diabetes
Society, 2013). Longer duration of Type 1 diabetes is associated with a lower
intensity of autonomic symptoms (Olsen et al., 2014).

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The most typical non-specific symptoms of general malaise include
headache and nausea (Joint British Diabetes Society, 2013). In clinical practice,
the team must clarify if the symptoms showed by the patients are related to
hypoglycaemic events or other conditions.
All things considered, this learning need helps the author to identify clearly
the symptoms of a hypoglycaemic episode. During the nursing practice, the
author can understand that hypoglycaemias happen quickly and an effective
intervention is essential. In all the hypoglycaemias observed, the author can
observe general malaise symptoms, and the neuroglycopenic symptoms are the
most uncommon observed, normally associated to severe hypoglycaemias.
Furthermore, this learning need helps the author to teach the patient and
the healthcare professionals about the different symptoms of hypoglycaemia. In
general, when a patient shows any symptom of hypoglycaemia, the nursing staff
increases the frequency of blood glucose level monitoring and the medical team
is informed. Coupled with the identification of the symptoms by the staff, the
recognition by the patient is very important as well. The patient is the first who
can feel the hypoglycaemic symptoms, but the communication between the
patient and the staff is crucial to have an immediate response to this event.

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SECOND LEARNING NEED
TO BE ABLE TO ACT IN A HYPOGLYCAEMIC EPISODE
Action Plan:
 Online research in EBSCO website with relevant and updated articles;
 Read updated literature and the latest guidelines;
 Complete an online e-learning Hypo Training Program, developed by
Diabetes.co.uk (see Appendix I);
 Observe and analyse clinical cases in the workplace environment.
Discussion:
The implementation of treatment strategies is fundamental to an efficient
resolution of hypoglycaemic episodes. An early identification of the symptoms
and a regular capillary monitoring of blood glucose are essential steps to
implement a profitable hypoglycaemic treatment plan. Furthermore, the
awareness of the hypoglycaemia care pathway adopted in the clinical service is
imperative as well, in order to use the most appropriate interventions according
to the severity of the hypoglycaemia (Joint British Diabetes Society, 2013).
The use of hypo boxes is another appropriate intervention in order to get
an active response in case of a hypoglycaemic event in the clinical area. It should
take a permanent place, and should always be fully stocked with all resources to
treat a hypoglycaemia (Joint British Diabetes Society, 2013).
The consumption of carbohydrates for patients who can have oral intake
is one of the measures to increase the blood glucose level. The patient should
take 15 to 20 grams of carbohydrates (The Endocrine Society, 2009; Holt, 2011).
It is equivalent to the consumption of 175ml of fruit juice, 5-7 glucose tablets, 1-2
oral glucose gels, 90-120ml of lucozade® or 3 to 4 full spoons of sugar dissolved
in water (Joint British Diabetes Society, 2013). The capillary blood glucose level
should be monitored 15 minutes after the hypoglycaemic episode. If the blood
glucose still low, the patient should take more 15 grams of carbohydrates.
This process should be repeated for the maximum of three times; if the
blood glucose level does not improve, the utilisation of intravenous therapy with
glucose is required. When the blood glucose reaches a level above 4mmol/l, the

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patient should take a long-acting carbohydrate, in order to keep a stable blood
glucose. A slice of bread, two biscuits or a cup of milk are examples of long-acting
carbohydrates (Joint British Diabetes Society, 2013; Holt, 2011).
In cases of patients who have frequent nocturnal hypoglycaemias, it is
appropriate the advice of the consumption of bedtime snacks, such as 2 biscuits
or a cup of milk (Joint British Diabetes Society, 2013).
If the patient is unresponsive or cannot have any oral intake, the team
should adopt the administration of intravenous glucose, or, in cases of no
intravenous access, the administration of one milligram of glucagon, via
intramuscular (The Endocrine Society, 2009; Joint British Diabetes Society,
2013). The use of the glucagon takes 15 minutes to act into the human body. The
use of intravenous glucose takes 10 minutes to be infused, in the case of the use
of 75-80ml of 20% glucose (Joint British Diabetes Society, 2013). If the patient is
in an insulin infusion therapy, commonly called sliding scale, the insulin rate
should be stopped and the intravenous fluid therapy should be substituted to
glucose (Joint British Diabetes Society, 2013).
However, the treatment of hypoglycaemias can easily convert to
hyperglycaemias, due to the use of excessive carbohydrates or glucose therapy
to treat the low blood glucose level. Therefore, the team should monitor frequently
the blood glucose level, until achieved stable results (The Endocrine Society,
2009).
Also, the identification of the cause for the hypoglycaemic episode is
crucial in order to prevent future events and change the current management of
diabetes. In cases of recurrent hypoglycaemias, the modification of anti-diabetic
medication and insulin regimen should be considered (The Endocrine Society,
2009).
In conclusion, this learning need helps the author to understand how to
manage a hypoglycaemic event. In clinical practice, the author is able to adapt
the appropriate interventions according to the patient status and how acutely is
the blood glucose level. In the clinical area, the advice for bedtime snacks
consumption evidences a reduction in hypoglycaemias. Also, in the case of
insulin intravenous therapy through sliding scale, the monitoring of blood glucose
is done more regularly, normally every three hours. The frequency is adjustable
according to the regularity of the blood glucose level. Normally, when patients

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use sliding scale therapy, the intravenous infusion of glucose reveals more
efficient to maintain a stable blood glucose level, instead of normal saline
infusion.
Furthermore, it is common that the patients felt the fear of more
hypoglycaemic events. Clearly, this feeling has a huge impact in the self-
management of diabetes and in the general wellbeing of the patient (Martyn-
Nemeth et al., 2015). In the clinical practice, when a patient experiments a
previous hypoglycaemic episode, the patient asks the nursing staff to monitor the
blood glucose level frequently, in order to predict a lower level. Also, it makes the
patient very anxious, and disturbs the regular intake of food. Therefore, this
learning need helps the author to teach the patients to maintain their regular diets
in order to keep the blood glucose level stable.
In cases of diabetic patients who cannot take any oral intake for a
prolonged time, the administration of intravenous glucose fluid is recurrent. These
patients, due to the nutritional deficit, do not take any anti-diabetic medication
until starting to have a regular intake.
The regular check of the diabetic box in the clinical area is done daily, in
order to be so important in cases of hypoglycaemic episodes.

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THIRD LEARNING NEED
TO BE ABLE TO PREVENT A HYPOGLYCAEMIC EPISODE
Action Plan:
 Online research in EBSCO website with relevant and updated articles;
 Read updated literature and the latest guidelines;
 Complete an online e-learning Hypo Training Program, developed by
Diabetes.co.uk (see Appendix I);
 Observe and analyse clinical cases in the workplace environment.
Discussion:
The hypoglycaemias can cause a dangerous risk of cardiovascular
complications, and even the death (Joint British Diabetes Society, 2013).
Therefore, the healthcare professionals should prevent and reduce the risk
factors by recognising the symptoms associated to it (Munoz et al., 2012).
On the other hand, the prevention of hypoglycaemias is helpful to reduce
the hospital stay. The occurrence of hypoglycaemias increased the stay of the
patients in the hospital (Turchin et al., 2009). In all cases, the discharge plan is
delayed until the nursing staff can find a stable blood glucose level.
Hypoglycaemic events are usual when people are admitted to the hospital.
It occurs in 7.7% of the admissions (Turchin et al., 2009). Hypoglycaemic
episodes require a longer stay in the hospital, and increase the inpatient mortality
(Turchin et al., 2009). According to Nirantharakumar (et al., 2012), the stay in the
hospital increases 51% in cases of mild and moderate hypoglycaemias, and
113% in cases of severe hypoglycaemias. Related to the mortality, it increases
62% in mild and moderate hypoglycaemias, and 105% in severe hypoglycaemia.
Basically, the prevention of hypoglycaemias is done through two different
measures: adjustments in the treatment regimen and continual education (The
Endocrine Society, 2009)
Bedside monitoring of the capillary blood glucose level is the priority to
prevent any hypoglycaemic event. This examination should be done four times a
day, 30 minutes before the main meals, and at the bedtime (The Endocrine
Society, 2009). On other hand, patients who are in enteral or parenteral feeding,

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or cannot have any oral intake, the performance of the blood glucose level
monitoring should be done more frequently (Joint British Diabetes Society, 2013).
In cases of insulin-dependent patients, the choice of the diet is important
as well, in order to adapt the insulin regimen according to the amount of
carbohydrates taken by the patient (The Endocrine Society, 2009). A consistent
carbohydrates intake, together with a regular meal time service, is crucial to
obtain a stable blood glucose level. Therefore, in a hospital environment, the food
service should be done always at the same time, and the performance of exams
or procedures at the same time of the meal service should be avoided, in order
to the patient do not miss it and, consequently, has a hypoglycaemic episode.
The prevention of prescribing errors is another issue in inpatients cases.
These practices include the use of trailing zeros after decimal points or
misinterpreted abbreviations (“U” of units in cases of insulin prescriptions) (The
Endocrine Society, 2009). Obviously, it can compromise the patient safety, and
develop severe complications.
The communication between the nursing staff and the medical team is
crucial as well. The awareness about the patient status and the current
administration of diabetic medication is an issue that needs to be reviewed as
soon as the patient is admitted (Munoz et al., 2012). The communication between
the multidisciplinary team is important also in order to implement efficient care
pathways (The Endocrine Society, 2009).
Summary, this learning need helps the author to understand the
importance of preventing a hypoglycaemic episode and which are the best
measures to make it. In the clinical practice, the most current issue found by the
author is the appropriate nutritional management. Patients still experience
delayed or missed meals, due to the realization of exams or procedures. These
events increase the probability of hypoglycaemias. Also, it can be observed by
the author the attempt to associate the drug administration with the meal service,
in order to administer the anti-diabetic medication and the insulin therapy on the
correct time.
The self-administration of the insulin is another issue. Normally, patients
in a hospital environment have a less intake of carbohydrates, however, they still
administer the same dose of insulin. The realization of this learning need alerts
for the importance of the communication between the staff and the patient. The

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continual education of the patients about the difference in the insulin regimen as
an inpatient is required (Munoz et al., 2012).

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FOURTH LEARNING NEED
TO BE ABLE TO IDENTIFY AND MANAGE A DIABETIC FOOT ULCER
Action Plan:
 Online research in EBSCO website with relevant and updated articles;
 Read updated literature and the latest guidelines;
 Complete an online e-learning module “Diabetic foot screening”,
developed by NHS Scotland (see Appendix II);
 Observe and analyse clinical cases in the workplace environment.
Discussion:
In diabetes, the damage caused by the high concentration of glucose in
the smalls vessels can origin microvascular complications, such as neuropathy,
nephropathy or retinopathy (NICE, 2015c).
Neuropathy is the damage or degeneration of the nerve. Approximately
10% of people with diabetes have diabetic foot ulcer (NICE, 2015a). The foot
ulcers are defined as an injured skin in the foot, causing the progressive
destruction of the skin and cells. In the major of the cases, it results in amputation
(NICE, 2015). The risk of amputation is 20 times more likely in diabetic people
than with the other population (Kerr, 2012).
The most common causes of foot ulcers are peripheral neuropathy,
gangrene, infection and Charcot arthropathy (NICE, 2015). The risk of foot ulcer
increases in cases of previous amputation, peripheral neuropathy, foot deformity,
visual impairment, diabetic nephropathy and poor glycaemic control (American
Diabetes Association, 2014). Therefore, it requires an acutely early diagnosis,
and a closer assessment and frequently reviews by the multidisciplinary team
(Turns, 2015; Diabetes UK, 2012).
In the community, the diabetic patients need an annual foot assessment
(NICE, 2015a). During the examination of the feet, the team need to remove
shoes, socks, bandages and dressings (NICE, 2051a).
The foot ulcer assessment includes a neurological, vascular,
dermatological and musculoskeletal review (Turns, 2015). In the neurological
assessment, the team should make the 10g monofilament test screening. The

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vascular assessment includes the check of both foot pulses. In the dermatological
assessment, the team should review the skin status, the presence of any
infection, ulceration or calluses. And, finally, the musculoskeletal assessment
includes the review of any deformity and the presence of Charcot joint (Turns,
2015).
In cases of diabetic patients being hospitalised, these assessments should
be done on the admission (NICE, 2015a). Also, the multidisciplinary teams should
be referred, including tissue viability, diabetic team, podiatrist and vascular team,
in cases of ischaemia (Turns, 2015). The communication between all the
multidisciplinary team is fundamental in order to get an effective treatment and
recovery. Also, the referral for the nutrition team is important, advising about the
best food choices to improve the wound healing (NICE, 2015a).
Furthermore, the infection control is one of the biggest alarms, when a
wound is diagnosed. A wound swab should be sent immediately to the
microbiologist (Turns, 2015). In cases of suspicion of infection, the antibiotic
therapy should be started (Turns, 2015).
The diabetic foot ulcer not only have a huge physically impact, reducing
the mobility and causing pain and discomfort, but also, the psychological aspect
is affected, decreasing the quality of life of the patient (Turns, 2015).
Obviously, the continual education is the key to the prevention of foot ulcer.
Diabetic patients should be advised about the footwear and the foot care (NICE,
2015a).
In conclusion, this learning need helps the author to understand the
diagnosis and management of the diabetic foot ulcer. In the clinical practice, the
author did not have any contact with diabetic foot ulcers, however, this review
helped the author to improve the knowledge and the skills about it.
In the clinical practice, the skin of all patients is examined every day, with
a special care in the heels, especially for the patient who have mobility problems
and cannot lift up the feet. In cases of foot ulcers, the examination is done hourly,
and the patient is advised to change the position frequently. Also, in cases of foot
ulcers, the communication between the multidisciplinary team is fundamental in
order to get the appropriate intervention. This multidisciplinary review is referred
to the community, when the patient is discharged.

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REFERENCES
American Diabetes Association (2014) ‘Diagnosis and classification of
Diabetes Mellitus’, Diabetes Care, 37(1), pp. S81-90, CINAHL [Online]. Available
at: http://care.diabetesjournals.org/content/37/Supplement_1/S81.full.pdf+html
(Accessed: 25 April 2016)
British National Formulary (2016) Sulfonylureas. Available at:
http://www.evidence.nhs.uk/formulary/bnf/current/6-endocrine-system/61-drugs-
used-in-diabetes/612-antidiabetic-drugs/6121-sulfonylureas#PHP4131
(Accessed: 1 May 2016)
Diabetes UK (2012) Putting feet first: commissioning/planning a care
pathway for foot care services for people with diabetes. Available at:
https://www.diabetes.org.uk/Documents/Professionals/Education%20and%20sk
ills/Footcare-pathway.0212.pdf (Accessed: 15 April 2016)
Holt, P. (2011) ‘Effective management of hypoglycaemia in diabetes’.
Nursing Prescribing, 9(12), pp. 588-592, CINAHL [Online]. Available at:
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=7f722921-2df1-
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May 2016)
Joint British Diabetes Society (2013) ‘The Hospital Management of
Hypoglycaemia in Adults with Diabetes Mellitus’. Newcastle Upon Tyne: Joint
British Diabetes Society. Available at: http://www.diabetologists-
abcd.org.uk/subsite/JBDS_IP_Hypo_Adults_Revised.pdf (Accessed: 20 April
2016)
Kerr, M. (2012) Foot care for people with diabetes: the economic case of
change. Fact Sheet 37, NHS Diabetes. Available at:
https://www.diabetes.org.uk/Documents/nhs-diabetes/footcare/footcare-for-
people-with-diabetes.pdf (Accessed: 14 April 2016)

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Martin-Nemeth, P.; Farabi, S.; Mihailescu, D.; Nemeth, J.; Quinn, L. (2016)
‘Fear of hypoglycaemia in adults with type 1 diabetes: impact of therapeutic
advances and strategies for prevention – a review’, Journal of Diabetes and Its
Complications, 30(1), pp. 167-177, ScienceDirect [Online]. Available at:
http://www.jdcjournal.com/article/S1056-8727(15)00373-6/pdf (Accessed: 30
April 2016)
Munoz, C.; Lowry, C.; Smith, C. (2012) ‘Continuous quality improvement:
hypoglycaemia prevention in the post-operative surgical population’, MedSurg
Nursing, 21(5), pp.275-280, CINAHL [Online]. Available at:
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May 2016)
National Institute for Health and Care Excellence (2015a) Diabetic foot
problems: prevention and management. Available at:
https://www.nice.org.uk/guidance/ng19/resources/diabetic-foot-problems-
prevention-and-management-1837279828933 (Accessed: 30 April 2016)
National Institute for Health and Care Excellence (2015b) Type 1 diabetes
in adults: diagnosis and management. Available at:
https://www.nice.org.uk/guidance/ng17 (Accessed: 13 April 2016)
National Institute for Health and Care Excellence (2015c) Type 2 diabetes
in adults: management. Available at:
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management-1837338615493 (Accessed: 30 April 2016)
Nirantharakumar, K.; Marshall, T.; Kennedy, A.; Narendran, P.; Hemming,
K.; Coleman, J. (2012) ‘Hypoglycaemia is associated with increased length of
stay and mortality in people with diabetes who are hospitalized’, Diabetic
Medicine, 29(12), pp. c445-c448, MEDLINE [Online]. Available at: http://0-
eds.a.ebscohost.com.brum.beds.ac.uk/eds/pdfviewer/pdfviewer?sid=b84416bb-

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0269-494f-8b98-63d12f9606f8%40sessionmgr4003&vid=12&hid=4208
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Olsen, S.; Asvold, B.; Frier, B.; Aune, S.; Hansen, L.; Bjorgaas, M. (2014)
‘Hypoglycaemia symptoms and impaired awareness of hypoglycaemia in adults
with type 1 diabetes: the association with diabetes duration’, Diabetic Medicine,
31(10), pp. 1210-1217, MEDLINE [Online]. Available at: http://0-
eds.a.ebscohost.com.brum.beds.ac.uk/eds/pdfviewer/pdfviewer?sid=b84416bb-
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(Accessed: 13 April 2016)
Rogers, H.; Zoysa, N.; Amiel, S. (2011) ‘Patient experience of
hypoglycaemia unawareness in Type 1 Diabetes: are patients appropriately
concerned?’, Diabetic Medicine, 29(3), pp. 321-327, MEDLINE [Online].
Available at: http://0-
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(Accessed: 13 April 2016)
Schopman, J.; Geddes, J.; Frier, B. (2010) ‘Frequency of symptomatic and
asymptomatic hypoglycaemia in type 1 diabetes: effect of impaired awareness of
hypoglycaemia’, Diabetic Medicine, 28(3), pp. 352-355, MEDLINE [Online].
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(Accessed: 13 April 2016)
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Hypoglycaemic Disorders: an endocrine society clinical practice guidelines,
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(Accessed: 2 May 2016)
Turchin, A.; Matheny, M.; Shubina, M.; Scanlon, J.; Greenwood, B.;
Pendergrass, M. (2009) ‘Hypoglycaemia and clinical outcomes in patients with

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diabetes hospitalized in the general ward’, Diabetes Care, 32(7), pp. 1153-1157,
CINAHL [Online]. Available at:
http://care.diabetesjournals.org/content/32/7/1153.full.pdf+html (Accessed: 29
April 2016)
Turns, M. (2015) ‘Prevention and management of diabetic foot ulcers’,
British Journal of Community Nursing, 20(Sup3), pp. S30-37, CINAHL [Online]
Available at:
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28 April 2016)

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APPENDIXES

18. 18
APPENDIX I

19. 19

20. 20
APPENDIX II

21. 21
Miss Monica Roque
Diabetes foot screening
16 April, 2016