Guidelines for diabetes management in pregnancy yoga,nurses relate the contributing factors involved in medication errors journal of clinical nursing,type 1 diabetes cure may 2012 28 - Plans On 2016


NB: We use cookies to help personalise your web experience and comply with Irish healthcare law. This site contains information, news and advice for healthcare professionals.You have informed us that you are not a healthcare professional and therefore we are unable to provide you with access to this site. Diet, exercise, and education remain the foundation of all type 2 diabetes treatment programmes. After metformin, it is reasonable to consider combination therapy with an additional 1-2 oral or injectable agents with the objective of minimising side-effects where possible.
For many patients insulin therapy alone or in combination with other agents will ultimately be required to maintain glucose control.
All treatment decisions, where possible, should take into account the patient’s preferences, needs and values. Diabetes may be diagnosed based on HbA1c criteria or plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT). For all patients, particularly those who are overweight or obese, testing should begin at age 45 years.
Two primary techniques are available to assess the effectiveness of glycaemic control: Patient self-monitoring of blood glucose (SMBG) or interstitial glucose and A1C.
Patients on multiple-dose insulin or insulin pump therapy should perform SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycaemic, and prior to critical tasks such as driving. Initial therapy: Most patients should begin with lifestyle changes – healthy eating, weight control, increased physical activity, and diabetes education. Advancing to dual combination therapy: If the HbA1c target is not achieved after ~3 months with metformin, there are six drug choices including a second oral agent (sulfonylurea, TZD, DPP-4 inhibitor, or SGLT2 inhibitor), a GLP-1 receptor agonist, or basal insulin.
Advancing to triple combination therapy: Evidence suggests that there is some advantage in adding a third noninsulin agent to a two-drug combination not achieving the glycaemic target. Do you agree that private hospitals should be paid via the NTPF to cut public hospital waiting lists? High blood pressure is one of the most common conditions that patients present with in family medical practice.
Recently, new modified guidelines for high blood pressure classification and treatment have been released.
3)  Race is a factor when choosing a type of medication for treatment of high blood pressure in adults under 60 years of age.
Also, new guidelines focus on implementing lifestyle interventions such as weight loss, diet and exercise at all times of high blood pressure management regimen. The threshold for normal blood pressure has been increased because there is not enough medical evidence to support that treating mild elevation in blood pressure can significantly reduce risks associated with high blood pressure such as stroke and heart attack.
Nevertheless, elevation in the blood pressure increases one’s risk of heart attack, stroke, developing chronic kidney disease, vision loss, as well as, premature death. For the best possible experience using our website we recommend you upgrade to a newer version or another browser. The Nursing and Midwifery Council could face “multiple risks” from the UK’s decision to leave the European Union, including a reduction to its income, it has warned.
I was invited recently to present my PhD research project on dementia to a patient and public involvement (PPI) group. What if I told you there was a new treatment being used to relieve depression and anxiety, and its side effects include improved fitness, weight loss and social integration? Choose your subscription package 1 – 9 subscriptions Student subscription 30+ subscriptions 1 – 9 subscriptions Our subscription package is aimed at qualified nurses to help support CPD and improve the quality and delivery of care given to patients.Select Student subscription This subscription package is aimed at student nurses, offering advice and insight about how to handle every aspect of their training.
When patients are in good medical and nutritional condition, with normal blood flow, acute wounds should heal normally. Even when known, the problems that delay healing are often complex and difficult to treat (Attinger and Bulan, 2001). There are many types of chronic wound, including leg ulcers, diabetic foot ulcers, pressure ulcers, dehisced surgical wounds, complicated burns and fungating wounds. Good nutrition is vital to optimise healing, so regular nutritional screening should be undertaken and the results acted upon. Inflammation is a necessary and healthy response to injury, delivering defensive materials (blood cells and fluid) to the affected site. The inflammatory process initiates repair and is arguably the most important stage of healing. A number of conditions – including advancing age, diabetes, pressure, arterial or venous disease, dead tissue and infection – can impair the circulation, leading to prolonged poor tissue oxygenation (Guo and DiPietro, 2010).
Proteases are secreted by the cells involved in the repair process, such as fibroblasts and endothelial cells, and are also produced by immune cells stimulated by the inflammatory response or by infection. In the normal course of wound healing, there is an initial increase in matrix metalloproteases (MMPs), which peaks at about day three and starts to reduce by around day five.
MMP activity decreases significantly as healing occurs in chronic leg ulcers, mirroring the processes observed in normally healing acute wounds.
When skin is damaged, micro-organisms that are normally found on its surface gain access to the underlying tissues. Bacteria can also stick together and develop a protective biofilm that shields them from the phagocytic activity of invading neutrophils (the most abundant circulating blood leukocytes).
It is likely that the presence of biofilms containing Pseudomonas aeruginosa are the cause of many non-healing wounds (Fig 1, attached).
All patients with leg ulcers should be assessed for arterial disease before compression therapy is initiated (Fig 2, attached). In arterial ulcers, restoration of blood flow by revascularisation is the intervention most likely to lead to healing.
When the Doppler results demonstrate venous disease (Fig 3, attached) or mixed arterial and venous disease, compression is vital to stimulate healing. Compression does this by reducing oedema in the leg and therefore restoring oxygen and nutrient supplies to the skin. The compression bandage fulfils the function of damaged valves, with graduated compression forcing the blood up the legs and reducing oedema. The Lindsay Leg Club Foundation aims to empower patients with leg problems through ­community-based leg clubs and can be helpful to patients with leg ulcers.
Diabetic foot ulcers (Fig 4) are a serious complication of diabetes and precede 84% of all diabetes-related lower-leg amputations (Brem and Tomic-Canic, 2007). Although a diabetic foot ulcer might look like a healing wound, it can become a portal for infection that can lead to sepsis and require limb amputation (Brem and Tomic-Canic, 2007).


Infections are a serious complication in diabetic foot ulcers and increase the risk of amputation.
Restoration of oxygen levels (blood supply) to the leg is also vital, so shoes should be checked for pressure points and patients referred to a podiatrist for offloading devices if necessary. Blood glucose levels and nutritional status should also be checked, as these are of particular concern and can adversely affect the wound-healing process. Pressure ulcers (Fig 5, attached) are caused by prolonged pressure, friction or shearing forces and the vast majority could be avoided if all the necessary prevention measures are in place. Before dressings are selected, pressure on the affected area must be relieved and oxygen delivery to the skin optimised. Granulating tissue requires protection, for example, with foam dressings, hydrocolloids and silicone dressings. When the wound is dry, there is rarely colonisation, but when wet, it can become colonised and require protection against infection. Once the wound is debrided, activated carbon cloth (ACC), hydrofibres, silicone or foams can be considered. Surgical site infections, and wound and tissue dehiscence (rupture of the wound), are well-known post-operative complications, particularly following gastrointestinal surgery (Fig 6, atttached). The severity of surgical-wound complications range from mild cases needing local wound care and antibiotics, to serious cases requiring surgery and with a high mortality rate. Fungating wounds (Fig 7, attached) are a particular type of non-healing wound associated with advanced cancers. It is important to consider patients’ psychosocial needs, as well as their clinical condition, when suggesting treatments. Keeping the wound clean is important, as fungating wounds can be the seat of infection or colonisation. All chronic wounds have some similarities in terms of depleted oxygen to the tissues and colonisation that can lead to clinical infection.
Addressing the lack of oxygen to a wound, reducing the potential for clinical infection, applying the appropriate dressing and undertaking holistic patient assessment are all vital elements of preventing and healing chronic wounds. For more on this topic see the following article: Stockings or bandages for leg-ulcer compression?
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Barrick B et al (1999) Leukocyte proteinases in wound healing: roles in physiologic and pathologic processes.
Cole-King A, Harding KG (2001) Psychological factors and delayed healing in chronic wounds.
Colin D et al (1996) Comparison of 90 degrees and 30 degrees laterally inclined positions in the prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures. Gouina JP, Kiecolt-Glasera JK (2011) The impact of psychological stress on wound healing: methods and mechanisms.
Lebrun I et al (2009) Bacterial toxins: an overview on bacterial proteases and their action as virulence factors. Loots MA et al (1998) Differences in cellular infiltrate and extracellular matrix of chronic diabetic and venous ulcers versus acute wounds. Mustoe TA et al (2006) Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis.
Saap LJ, Falanga V (2002) Debridement performance index and its correlation with complete closure of diabetic foot ulcers. Sorensen LT et al (2005) Risk factors for tissue and wound complications in gastrointestinal surgery. Diabetes may be identified in seemingly low risk individuals who happen to have glucose testing, in symptomatic patients, and in higher-risk individuals who are tested because of a suspicion of diabetes.
When lifestyle efforts alone have not achieved or maintained glycemic goals, metformin monotherapy should be added at, or soon after, diagnosis (in patients intolerant, or with contraindications for, metformin, select initial drug from other treatment options). The ‘wonder drug’ in question is a smartphone game called Pokemon Go and you’re going to hear a lot about it. Select 30+ subscriptions Our package is designed for organisations who want to purchase access and benefit from a group saving. While most acute wounds will heal with the right treatment, some get stuck along the normal healing pathway and become chronic. In chronic wounds, however, healing is more problematic, as the underlying causes of the wound are more difficult to determine. Chronic wounds are defined as wounds that have failed to proceed through an orderly and timely healing process over a period of three months (Mustoe et al, 2006). Each type has its own particular traits and complications, although in all cases, the delayed healing can be linked to poor blood supply or infection, with poor nutrition also playing a key role (Attinger and Bulan, 2001).
There is evidence that psychological stress and other behavioural factors can also affect wound healing (Gouina and Kiecolt-Glasera, 2011), and patients who experience the highest levels of depression and anxiety are four times more likely to be categorised in the delayed healing group, compared with individuals who report less distress (Cole-King and Harding, 2001).
In normal wound healing it is a carefully controlled balance of destructive processes that are necessary to remove damaged tissue and repair processes that lead to new tissue formation (Cullen et al, 2002). Vascular disruption and high oxygen consumption by metabolically active cells can deplete the micro-environment of the wound of oxygen, causing wound hypoxia. In acute wounds, they are essential for the healing process, but in chronic wounds or chronic inflammation, they become destructive to wound healing.
Bacterial proteases, present when bacteria are in a pathogenic state (Lebrun et al, 2009), add to the cocktail, stimulating a further immune response. In non-healing wounds, however, not only do proteases reach higher levels than in healing wounds, but they persist for far longer, resulting in a highly destructive wound environment (Wounds International, 2011). This supports the case for the addition of protease inhibitors in chronic wounds (Wounds International, 2011).
This mechanism may explain the failure of systemic antibiotics as a remedy for chronic wounds (Bjarnsholt et al, 2008). If tests show that an ulcer is likely to be due to poor arterial flow, the patient should be referred to the vascular team, who will aim to restore the oxygen and nutrient supply to the limb, either through angioplasty or bypass surgery, or through medication.
Oedema is caused by venous insufficiency, in which damaged venous valves allow backflow of blood, which pools in the legs instead of returning to the heart.
They provide leg-ulcer management in a social environment; in addition to improving healing rates and reducing recurrence, they can reduce social isolation and stress levels, as well as improving patients’ general wellbeing.


More than 100 known physiological factors contribute to wound-healing deficiencies in people with diabetes and, coupled with an impaired ability to fight infection, these patients become largely unable to mount an adequate inflammatory response. These ulcers often require debridement to stimulate healing (Saap and Falanga, 2002), but this should only be performed by clinicians who have been fully trained in debridement of the diabetic foot.
If a patient presents with a pressure injury, it is worth checking the necessary equipment is in place, and the people caring for the patient know how to use it and understand prevention techniques.
Colin et al (1996) demonstrated a dramatic impairment of oxygen supply to the skin in the 90-degree laterally inclined position but not in the 30-degree laterally inclined position.
TNP therapy uses a sealed dressing connected to a vacuum pump, and draws out fluid while promoting bloodflow. Patients should receive appropriate preoperative preparation for surgery and postoperative care, as described in the NICE (2008) guidelines. Other causes include haematoma, nutrition, vascular supply, oedema and patient interference. Since these wounds are unlikely to heal, nurses should focus on different management objectives. For example, offering maggot therapy to someone with a potentially terminal disease could be a reminder of the process of death, while leakage or offensive odour may be causing significant psychological distress. These wounds are mostly colonised by anaerobic bacteria, which creates a very offensive odour. Reducing the occurrence of chronic wounds would save money for the NHS, free nurses to spend time on other essential care and, most importantly, improve outcomes for patients. Shared decision making with the patient is important to help in the selection of therapeutic option.
Since diabetes is associated with progressive beta-cell loss, many patients, especially those with long-standing disease, will ultimately need to be transitioned to insulin. The pathology of these wounds is complex, requiring nurses to determine and eliminate any underlying problems, such as poor circulation, while preventing colonisation to avoid infection. These wounds have become stuck in one of the phases of wound healing, generally considered to be chronic inflammation (Guo and DiPietro, 2010).
There are also wounds that will not heal without medical intervention, such as some arterial wounds, breast cancer or wounds with clinical infection. Acute inflammation defends damaged tissues against bacterial invasion, while delivering mediators to stimulate the wound-healing process (Majno and Joris, 1996).
In normally healing wounds, this hypoxia is temporary and actually triggers healing; prolonged or chronic hypoxia, however, delays wound healing (Bishop, 2008). A key feature of non-healing wounds – and a major consequence of the persistent inflammatory response at the wound site – is unrestrained proteolytic activity, which overwhelms local tissue protective mechanisms. A range of products can inhibit MMP activity and make the wound environment unsuitable for bacteria. If the result is outside this range, the patient is likely to have arterial disease and the advice of a vascular specialist nurse or GP should be sought. These include regular repositioning and the use of pressure-relieving equipment, as appropriate, following a full risk assessment of the patient (National Institute for Health and Care Excellence, 2014). Pressure should therefore be reduced by placing the patient in a 30-degree position, and appropriate dressings for the individual wound selected. These include hydrogel sheets, amorphous hydrogel, honey, and hydrofibres, while maggot therapy can also be used. In most cases, such complications prolong hospitalisation, with a substantial increase in cost of care (Sorensen et al, 2005). Care should be palliative, addressing uncomfortable and distressing symptoms, rather than offering the aggressive treatments that strive for an optimum healing environment. Patients must be fully involved in any decisions about wound treatments and dressings, and their individual needs should be considered at all times. However, colonisation, which can be addressed by antimicrobial dressings, is often mistaken for clinical infection, which requires antibiotics. The choice is based on patient and drug characteristics, with the over-riding goal of improving glycaemic control while minimising side-effects.
Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Also, all diagnosed patients were initiated on the same medication, without regard to the race, once elevation of blood pressure was noted on three separate occasions. At the physical share the results with the medical provider to determine the necessity of medication.
Through appropriate treatment and the correct dressing choice, nurses can help prevent a chronic wound from getting worse and put it back on the path to healing.
The wounds fail to progress through the normal phases of healing, and remain in a chronic inflammatory state (Loots et al, 1998). There is compelling evidence that unrestrained protease activity is one of the major underlying abnormal responses of non-healing wounds (Barrick et al, 1999). TNP can be effective for these wounds as it encourages oxygen into the tissues and removes bacteria, although it is not always a suitable and cost-effective choice for every wound that has dehisced. The first priority is to control pain, odour, bleeding and exudate; removal of necrotic tissue is a lower priority. Some wounds will never be able to heal; in such cases, nurses can help to relieve patient discomfort.
For example it should not be used on wounds associated with cancer or wounds that connect to a body organ. For more information about wound pain assessments, see part three of this series (Brown, 2015b).
In using triple combinations the essential consideration is obviously to use agents with complementary mechanisms of action. TNP should not be used on exposed organs without special dressings produced specifically for this situation.



Facts about medical errors
Type 2 diabetes and the atkins diet




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