0 - INTRODUCTION I, a student of 2nd Year / 1st Semester, School of Nursing of t

he Guard, I am conducting a training of six weeks during the period from May 14
to June 22 of the resulting year within Stage III, "Maternal Health and Obstetri
cs," in part of Community Health at the Health Center of Trancoso. During this s
tage I set myself to carry out a single school on the issue of diabetes, since i
t is a very common scourge in our society. Another reason to encourage me to dev
elop this theme was that sometimes I realize that there are many diabetics who l
ack sufficient knowledge about their disease and the care it demands. The teachi
ng was conducted on the premises of the Health Center of Trancoso, on June mmm,
mmm the people aged between mmm years. This objective was to illustrate to what
is diabetes, types of treatment, the care of their feet and clear up some questi
ons. To facilitate the understanding of the issue, some posters were presented (
Appendix 1).
1 - DIABETES MELLITUS
1.1 - DEFINITION OF DIABETES MELLITUS According to Seeley Tate (1996), Diabetes
Mellitus is a:
"(...) Metabolic disease in which the use of carbohydrates is reduced and lipid
and protein increased, caused by lack of insulin or an inability to respond to i
nsulin, is characterized, in severe cases, by hyperglycemia, glycosuria, loss of
water and electrolytes, ketoacidosis and coma. "
In accordance with Jorge Costa (1995, p.197), diabetes is a chronic and widespre
ad, which may develop in individuals with some susceptibility heredofamiliar and
manifests itself in its typical form, due to weakness, weight loss or difficult
y of growth, hyperglycemia, ketosis, acidosis and protein breakdown. Typically,
there is a certain amount of glucose circulating in the blood resulting in food
intake and the formation of glucose by the liver. Insulin is a hormone produced
by special cells of the islets of Langerhans, beta cells, the pancreas that cont
rols glucose levels in the blood, regulating the hepatic storage of glucose in t
he form of glycogen and its eventual transformation into lipid or proto (hormone
lipoglicemiante). In diabetes there may be an impairment of body respond to ins
ulin and / or a decrease or absence of insulin the pancreas.
1.1.1 - Types of Diabetes In agreement with Suzanne Smeltzer and Brenda Bare (19
95, p.873), there are several types of diabetes mellitus which differ in relatio
n to the cause, the disease course and treatment. The main classifications are:
Type I: Insulin-Dependent Diabetes Mellitus (IDDM) In this form of diabetes, a
re inadequate amounts of insulin produced by the pancreas, resulting in the need
for insulin injections to control blood glucose.
This type is characterized by sudden onset, usually before the age of thirty, be
ing caused by environmental factors (toxins, viruses, changes in humoral immunit
y, etc. ..) in genetically predisposed individuals. Type II: Diabetes Mellitus
, Non Insulin-Dependent (NIDDM) Type II diabetes results from a decreased sensit
ivity to insulin (insulin resistance), as well as a decrease in the amount of in
sulin produced. This type of diabetes most often appears after the age of forty
and obese individuals. It is initially treated by a diet, but if there is some p
ersistence of high levels of glucose, the diet is supplemented with oral hypogly
cemic agents. However, in some people with type II diabetes, oral agents are not
able to control hyperglycemia, so it is necessary to the administration of insu
lin. Other types of diabetes are found usually associated with other pathologi
es. These are the cases of diabetes associated with diseases of the pancreas or
endocrine, diabetes that can arise during pregnancy (Gestational Diabetes Mellit
us), etc. ..
1.1.2 - Prevention Consistent with Phipps, Long and Woods (1990, p. 81), prevent
ive health care to be taken in relation to Diabetes Mellitus can be primary or s
econdary. Primary prevention is directed to be made to avoid obesity and sometim
es lowering the weight in order to prevent the onset of NIDDM. Secondary prevent
ion aims at early detection and disease control. Screening programs can be carri
ed out in health departments, clinics, hospital facilities for outpatient care,
medical, industry, weight loss clinics or mobile health units offering
programs screening for diabetes. However, for a screening program to succeed it
is essential to monitor all positive findings. An important way to prevent diabe
tes is education. The health education programs must involve people of all ages,
especially people at risk (obese, elderly, people with a family history of diab
etes, ...); in schools and industries. People with diabetes should have declared
access to these educational practices, to support field maintenance, the social
support systems, medical and nursing care, it is possible for the prevention an
d early detection of complications.
1.1.3 - Clinical Manifestations According to Jorge Costa (1995, p.198), the mani
festations of Diabetes Mellitus are very varied and depend on several factors in
cluding: age of onset, the existence of other diseases, the rapid high sugar and
duration of disease, as well as, the resulting complications. As a result of th
e persistent increase in glucose there is an increased renal elimination of suga
r, causing sweet urine (hence the name "diabetes mellitus"). The presence of sug
ar in the urine draws water. Thus, diabetics, while urinating in large quantitie
s (polyuria), lose calories, which causes them to lose weight and feel a sense o
f increased hunger (polyphagia) and are dehydrated, condicionandolhes increased
thirst (polydipsia). These are often the first symptoms of diabetes mellitus or
chronic decompensated inaugural. Other early symptoms of diabetes mellitus can i
nclude diarrhea and abdominal pain as well as an increased frequency of urinary
infections or gynecological. However, especially in the presence of infections (
which are more frequent and more difficult to treat diabetics), trauma or any ph
ysical or mental stress, the first manifestations may be changes in level of con
sciousness, including coma, said cetoacidótico in diabetics type I and type II i
n hyperosmolar. There are frequent complaints of vision such as blurred vision r
esulting from the variation of sugar concentration at eye level. The forms of lo
ng-term cause serious complications at ophthalmologic, neurological, renal and c
ardiovascular systems.
1.1.4 - Diagnostic Evaluation In accordance with Suzanne Smeltzer and Brenda Bar
e (1995, p. 877), a person is considered diabetic when, in at least two evaluati
ons in fasting blood glucose value is less than 140 mg / dl , or if at any time
of day, there is equal or greater than 200 mg / dl accompanied by complaints str
ongly suggestive of diabetes. This value can be obtained by determination of glu
cose in a drop of blood by bite or through the collection of blood from a vein.
When levels of fasting glucose remain normal or near normal, the diagnosis shoul
d be based on a glucose tolerance test.
1.1.5 - Processing In agreement with Dr. Andrew Duranteau (1981, p. 175), the tr
eatment of Diabetes Mellitus is by general measures of behavior and specific med
ication. The main goal of diabetes treatment is to try to normalize the activity
of insulin and blood glucose levels, seeking to reduce the likelihood of develo
ping vascular and neuropathic complications. For Jorge Costa (1995, p.200) there
are five components in the treatment of diabetes, including diet, exercise, mon
itoring, medication (when necessary), and education. Treatment is variable durin
g the course of disease due to changes in lifestyle and physical and emotional c
ondition, as well as to advances in treatment resulting from research. Therefore
, the treatment of Diabetes Mellitus includes constant evaluations and modificat
ions of the plan by health professionals and daily adjustments in therapy by the
patient. Although the health care team to direct the treatment, the patient is
facing the daily challenge of managing the details of a complex treatment regime
n. Therefore, education of patients and their families is seen as an essential c
omponent of diabetes treatment.
1.1.5.1 - Processing diet diet and weight control are the basis for treatment of
diabetes. The nutritional diabetic patient has the following goals: 1 2 3 4 Pro
vide all essential food components, obtain and maintain ideal weight; Meeting th
e energy needs, prevent large diurnal variations in blood glucose levels and blo
od levels get the most close to normal in a practical and safe, 5 Lower blood le
vels of lipids, when elevated. For patients who require insulin to control blood
levels of glucose,€is important to maintain as constant as possible the amount
of calories and carbohydrates consumed in different meals. With respect to obese
patients (especially those with type II diabetes), weight loss is key in treati
ng diabetes and preventing the development of complications associated with path
ology. For all diabetics, food planning must take into account patient preferenc
es, your lifestyle, eating the usual times and its ethnic and cultural origins.
For those who use insulin, there may be more flexibility in schedules and conten
t of meals provided that the patient may, when necessary, to safely modify the d
ose of insulin.
1.1.5.2 - Exercise Physical activity consistent and realistic is beneficial for
older people with Diabetes Mellitus. The exercises are extremely important in th
e conduct of diabetes, since they reduce the blood glucose by increasing glucose
uptake by muscles of the body, improving insulin use. Also favor the movement,
muscle tone, weight loss, decreased stress and feelings of well-being. We can al
so consider that exercise alter the levels of high density lipoproteins and decr
eased levels of total cholesterol and triglycerides.
Patients participating in extended periods of exercise should test blood glucose
before, during and after the period of exercise, and eat snacks with carbohydra
tes when needed, to keep blood glucose levels. In obese people with type II diab
etes, exercise and dietary addition to the conduct improves glucose metabolism a
nd stress better insulin sensitivity and may decrease the need for insulin or or
al hypoglycemic agents. For many patients, the walk is a safe and beneficial exe
rcise. It requires no special equipment other than proper shoes.
1.1.5.3 - Monitoring of Glucose and Ketones The eighties was a time of rapid adv
ances in available technology for monitoring glucose. The development of methods
for self monitoring of blood glucose (AMGs) is seen as big news in the conduct
of diabetics since the discovery of insulin. The AMGs enables the detection and
prevention of hypoglycemia, hyperglycemia and normalization of blood glucose lev
els, allowing diabetics to gain some independence. For most patients who require
insulin, the test is recommended two to four times a day (usually before meals
and bedtime). Compared to patients who use insulin before each meal, you must pe
rform the test at least three times a day, to determine with certainty each dose
of insulin. Patients without insulin, can be instructed to monitor blood glucos
e levels at least two to three times per week. In general, the test is recommend
ed whenever there is any suspicion of hypoglycaemia or hyperglycaemia.
Glycosylated hemoglobin This is a blood test that reflects average blood glucose
levels over a period of about two to three months.
When blood glucose levels are high, a glucose molecule binds to hemoglobin in a
RBC. The longer the blood glucose is above normal, the greater the number of gly
cated hemoglobin. This complex (hemoglobin linked with glucose) is permanent and
lasts throughout the life of the erythrocyte, about 120 days. Where are maintai
ned blood glucose levels near normal, with only occasional highs, the overall va
lue is not very high. However, if blood glucose levels are persistently high, th
en the result of the tests will also be high.
Verification Test for Urine Glucose Before the availability of AMGs, the test of
glucosuria was the only method available for daily monitoring of diabetes. Howe
ver, today he has limited use in the treatment of diabetes. The procedure involv
es the application of a urine reagent strip and comparing the color of tape on t
he bottle.
Test to check urine ketones The presence of ketones (or ketone) in urine indicat
es that the control of type I diabetes is to deteriorate. When there are almost
no available effective insulin, the body starts using fat for energy. Ketones ar
e byproducts of the breakdown of lipids and accumulate in the blood and urine. C
urrently, the only method for self-assessment of ketones is the urine test.
1.1.5.4 - In compliance with insulin therapy Seeley Tate (1996), insulin is secr
eted by beta cells of islets of Langerhans.€It reduces blood glucose after meals
, facilitating the capture and utilization of glucose by muscle, liver cells and
fats. During periods of fasting, it inhibits the breakdown of glucose, protein a
nd fat storage. In type I diabetes, the body does not produce enough insulin. Th
us, it has to be administered indefinitely. In type II diabetes, insulin may be
necessary for the long term to control glucose levels if diet and oral hypoglyce
mic agents have failed. Furthermore, some patients whose Type II diabetes, is us
ually controlled by diet or diet and oral hypoglycemic agent, may require tempor
ary insulin during illness, pregnancy, surgery, or some other stressful event. O
ften, insulin injections are administered twice daily (or more) in order to cont
rol the increases in glucose after meals and overnight. The administration of in
sulin should be made in specific locations, and the patient often switch local a
dministration. The needle should be introduced with an angle of 45 º or 90 º in
adipose tissue and not muscle, being necessary to fold the tissue to enter the n
eedle. Figure 1 - Locations of insulin
Source: Phipps, Long and Woods (1990, p. 108)
Complications of insulin According to Suzanne Smeltzer and Brenda Bare (1995, p.
890), insulin may cause: Allergic-local: it is characterized by the appearance
of redness, swelling, tenderness and induration of local administration, or a ri
ng
two to four inches. This reaction comes about one or two hours after the injecti
on. The reaction usually occurs during the benign stages of therapy and may disa
ppear with continued administration of insulin. Systemic-allergic reactions: rea
ctions are very rare. Initially occurs in the skin an immediate local reaction t
hat gradually spreads in generalized urticaria. Faced with this situation, treat
ment is desensitization with small doses of insulin given in gradually increasin
g amounts. These reactions are occasionally associated with generalized edema or
anaphylaxis. Lipodystrophy-insulin: refers to a localized disorder of fat metab
olism, whether in the form of lipoatrophy or lipoipertrofia, which occurs at the
place of insulin.
1.1.5.5 - The Oral hypoglycemic agents Oral hypoglycemic agents may be effective
for patients with type II diabetes, since they can not be treated with an adequ
ate diet. The oral hypoglycemic agents available are the sulfoniluérias. They pr
esent as a secondary effect directly stimulating the pancreas functional so that
they become effective agents. These agents may not be used in the treatment of
patients with type I diabetes and are prone to ketoacidosis. It is important tha
t patients understand that oral agents are prescribed in addition (not replaceme
nt) to other treatment modalities, such as diet and exercise. Oral hypoglycemic
drugs may be temporarily abandoned in favor of insulin when patients develop hyp
erglycemia due to infection, trauma or surgery. If, over time, the values of glu
cose in the blood of patients fail to respond to oral hypoglycemic agents, the p
atient is then treated with insulin (secondary failure). A primary failure occur
s when the blood glucose level remains high a month after the initial drug.
1.2 - ACUTE COMPLICATIONS OF DIABETES According to Suzanne Smeltzer and Brenda B
are (1995, p.895), there are some important acute complications in diabetes-rela
ted short-term imbalances in blood glucose, including: hypoglycemia, diabetic ke
toacidosis, hyperosmolar syndrome not -ketonic hyperglycemia and early morning.
Hypoglycemia (insulin reactions) the hypoglycaemia (abnormally low blood glucose
) occurs when glucose falls below 50-60 mg / dl. It can be caused by excess insu
lin or oral hypoglycemic agents, poor nutrition or excessive physical activity.
Hypoglycaemia can occur at any time of day or night. Usually occurs before meals
, especially if meals are delayed or omitted snacks. Signs and symptoms of hypog
lycemia may include: pallor, tachycardia, sweating, palpitations, weakness, irri
tability, headache, seizures, blurred vision, coma, etc. ..
Diabetic Ketoacidosis Diabetic ketoacidosis is caused by the absence or inadequa
te amount of insulin and marked. This results in disturbances in the metabolism
of carbohydrates, proteins and fats.
Non-ketotic hyperosmolar syndrome The non-ketonic hyperosmolar syndrome is a con
dition in which hyperglycemia and hyperosmolarity with predominant sensory chang
es. At the same time, ketosis is minimal or even absent. The basic biochemical d
efect is the lack of effective insulin.
The patient's persistent hyperglycemia leads to osmotic diuresis, resulting in t
he loss of water and electrolytes. Morning hyperglycaemia A high level of blood
glucose in the morning may be due to insufficient levels of insulin (end of dawn
or Somogyi effect). The dawn phenomenon is characterized by relatively normal b
lood glucose until about three o'clock in the morning. About and from this time,
the blood glucose levels begin to rise. The phenomenon is taken as a result of
increases nocturnal secretion of growth hormone, which creates a need for insuli
n in the early morning hours in patients with diabetes type I.
1.3 - COMPLICATIONS OF DIABETES IN THE LONG TERM The long term complications of
diabetes, are becoming more common as more people live longer with diabetes. The
y can affect almost any organ system in the body. General complications of diabe
tes in the long run, according to Suzanne Smeltzer and Brenda Bare (1995, p. 907
) are: changes macrovascular (heart disease, cerebrovascular disease, peripheral
vascular diseases ,...), changes microvascular (diabetic retinopathy, neurofagi
as , neuropathies ,...).
1.3.1 - Problems of the Leg and Foot in Diabetes According to Suzanne Smeltzer a
nd Brenda Bare (1995, p. 907), diabetes can cause serious problems in the feet a
nd legs. Between fifty to seventy-five percent of lower extremity amputations ar
e performed in people with diabetes. Between fifty to seventy percent of amputat
ions can be avoided if potential problems are diagnosed in time and whether pati
ents are receiving appropriate treatment and follow some basic rules. The typica
l sequence of development of diabetic foot ulcers begins with a soft tissue inju
ry of the foot, forming a cleft between the toes, or
a dry area, or forming a callus. The damage is not perceived by the patient with
a foot callous. If the patient does not have the habit of inspecting your feet
daily, damage or tear can be missed. The redness of the leg or grangrena can be
the first signs that the patient notes indicative of problems in the feet. The t
reatment of foot ulcers involves bed rest, antibiotics and debridement. Furtherm
ore, the control of glucose levels, which tend to increase when infections occur
, it is important to promote healing. Amputation may sometimes be necessary to p
revent a subsequent infection. The guidelines on assessment and care of the feet
are very important when dealing with patients who have a high risk of developin
g foot infections. In a comprehensive way, patients considered at high risk have
the following characteristics:-duration of diabetes for over ten years;-age ove
r forty years, history of smoking, decreased peripheral-pulse;-sensitivity low;-
deformities or anatomical pressure areas (such as calluses and bunions)-history
of foot ulcers or amputation.
1.3.1.1 - Foot Care Consistent with Suzanne Smeltzer and Bare Brenda (1995, p. 9
05) along the vascular or venous settle the tertiary prevention is essential, es
pecially in terms of infection. This avoids the complications preventing designa
ted under the term "diabetic foot". 1. The diabetic should inspect their feet da
ily, looking for blisters, cuts, scratches, spots (especially around the nails),
scales or swelling. Must have attention between the toes. If the patient has di
fficulty in observing the feet, should seek the assistance of a family member. 2
. The nails should always be trimmed and eradicated without rounding the corners
.
3. Before cutting the nails, you should have your feet in warm water for fifteen
minutes and clean them very well. The patient should seek professional help if
any nail jams or if you have difficulty cutting your nails. 4. The patient shoul
d wash the feet daily with warm water and soap. The water temperature should alw
ays be checked by hand or by a relative. The patient should dry and feet careful
ly, especially between the toes, without rubbing the skin. 5. After drying the f
eet, the patient may make a slight massage with a soft cream lubricant, around t
he toes and heels. The patient should not put cream between the toes, but can ap
ply talcum powder between the toes. 6.€The patient should never apply strong ant
iseptics in the feet or legs, especially iodine, or solutes hypochlorite (bleach
smell, for example: Solute Dakin's). 7. If any court, it should be washed with
soap and disinfectant should think with an antibiotic ointment and sterile gauze
. The patient should not apply adhesive to the skin of the feet or legs, since t
hese can irritate skin and cause sores. 8. The patient should avoid extreme temp
eratures (hot or cold). The feet and legs should be protected from sunburn or co
ld. You should not use hot water bottles or radiators to warm their feet. If you
get cold feet in bed, the patient should wear a pair of cotton socks or wool. 9
. You should not wear socks with rubber bands, because they can produce a tourni
quet-like effect, and in turn lead to the onset of swelling in that area. The pa
tient must wear socks on their size and avoid the use of socks with embroidery o
r textures that can irritate the skin. The socks should be changed every day. 10
. The patient must wear shoes in their size, with soft insoles and flexible sole
s, preferably with adjustable laces. The sandals, which leave the toes exposed o
r heels are not advisable. Regarding the new shoes, they must be used gradually
to adapt to the feet.
The patient should check the inside of shoes daily, to make sure they do not con
tain foreign objects. If you find that the inner lining of the shoes is torn or
protrusions that can scratch, you should stop using them immediately. 11. The pa
tient should never walk barefoot, to avoid cuts or wounds. 12. Tobacco should be
avoided. 13. The patient should not use chemicals or blades to remove calluses
or warts (carnations). If these arise, seek professional help. 14. If the patien
t can not heal a single wound or if you suspect a more serious problem should co
nsult a doctor. If the problem persists should seek a specialist. The special ca
re of feet can prevent long-term effects of diabetes. However, vascular problems
and poor circulation can progress. Without immediate surgery in some situations
, may result the loss of the foot or leg. The loss of sensitivity, can cause ser
ious problems if preventive measures are not implemented. The loss of sensitivit
y by itself is not serious, but are the possible injuries that go unnoticed that
can create problems. Periodic consultations with the foot exams are extremely i
mportant for the prevention and treatment of problems caused by diabetes.
2 - CONCLUSION At the end of this teaching, little more can I add this conclusio
n also noted that this was an experience that contributed greatly to my personal
enrichment. My commitment to the development of this teaching was very helpful,
because that allowed me to gain deeper knowledge on the subject that was addres
sed. The teaching was not presented in the same way that is documented, as has b
een done to people whose level of understanding and knowledge was rather limited
. Thus, teaching was adapted so that the essential ideas were provided. As regar
ds the preparation and presentation of education we had no difficulties. In rela
tion to the objectives that were outlined by me earlier this school, it was my d
esire to reach them and I believe have done so. As a future nurse, individual ed
ucation to accomplish this not only allowed me to deepen my knowledge related to
diabetes, as well as understand some of the complexity of this disease and prep
are myself for my future and career stages, where the daily confrontation with d
iabetes will be somewhat common.
3 - BIBLIOGRAPHY COSTA, Jorge - Practical Guide to Health Lisbon: Terramar, 1995
. ISBN 972-710-121-6. DUARTE, Cristina - Education of the chronically ill. "Diab
etes, Living in Balance". Lisbon. ISSN 0873-450X. No. 17 (1999), 10-11. Durantea
u, André - Elementary Medical Dictionary. Lisbon: Publicações Europa-América, 19
81. FISHER, James, BARRY, and General [et al] - The World of Man. Portugal: Publ
icações Europa-América, 1969. MATOS, Pedro - Cardiac complications. "Diabetes, L
iving in Balance". Lisbon. ISSN 0873-450X. No. 11 (1999), 9-11. PHIPPS, LONG AND
WOODS - Medical-Surgical Nursing. Lisbon: Lusodidacta, 1990. ISBN 972-95-399-0-
I. SMELTZER, Suzanne and BARE, Brenda - Medical-Surgical. Rio de Janeiro: Guanab
ara Koogan, 1995. ISBN 85-277-0272-X.
SUMMARY Leaf 0 - INTRODUCTION ............................................. ....
.............................................. .......... 4 1 - DIABETES MELLITU
S ................................... ..........................................
............. 5 1.1 - DEFINITION OF DIABETES MELLITUS ..........................
................... ............... 5 1.1.1 - Types of Diabetes ................
........... .................................................. .................
.. 5 1.1.2 - Prevention ......................... ..............................
.................... .................................. 6 1.1.3-Clinical Manifes
tations ......... .................................................. ...........
.................... 7 1.1.4 - Diagnostic Evaluation ............ ..............
.................................... ........................... 8 1.1.5 - Treat
ment ................. .................................................. ......
.................................. 8 1.1.5.1 - Dietary Treatment ... ...........
....................................... ...................................... 9
1.1.5.2 - Financial ...... .................................................. .
................................................. .9 1.1.5.3 - Monitoring of Glu
cose and Ketones ....................................... .......................
.. 10 1.1.5.4 - Insulin ................... ....................................
.............. ............................. 11 1.1.5.5 - oral hypoglycemic agen
ts ............. .................................................. ....... 13 1
.2 - ACUTE COMPLICATIONS OF DIABETES .................................... ......
.......... 14 1.3 - LONG-TERM COMPLICATIONS OF DIABETES ........................
. ............ 15 1.3.1 - Problems of the Leg and Foot in Diabetes .............
............. ................................ 15 1.3.1.1 - Foot Care .........
.................................................. .............................
February 16 - CONCLUSION ................. ....................................
.............. ...................................... March 19 - BIBLIOGRAPHY ..
...... .................................................. ......................
..................... 20
APPENDICES Appendix 1 - Posters ............................................. ..
................................................ ........... 22
INDEX OF FIGURES Figure 1 Leaf - Places of insulin .............................
......... ........................ 12
ABBREVIATIONS Enf. Nd - Nurse P. - Page
ACRONYMS AMGs - self-monitoring of blood glucose NIDDM - Diabetes Mellitus, Non
Insulin-Dependent IDDM - Insulin-Dependent Diabetes Mellitus
ANNEXES
Annex 1
(Poster)