Background: Diabetes of all types can lead to complications in many parts of the body and can increase the overall risk of dying prematurely. Possible complications include heart attack, stroke, kidney failure, leg amputation, vision loss and nerve damage. In pregnancy, poorly controlled diabetes increases the risk of fetal death and other complications
Aim: The main purpose of this study was to assess the rehabilitative care of a patient with diabetic mellitus
Result: diabetic patients need rehydration therapy, reversing electrolyte and acidosis, monitoring, blood pressure control, self-management education, psychosocial intervention, and family and social support as rehabilitation.
Conclusion: The rehabilitation care should be given at all levels of health care delivery system to improve lifelong quality of diabetic patient, by preventing diabetic related burdens including social, economic and psychological impacts of the disease
Abbrevations: CAD: Coronary Artery Disease; DKA: Diabetic Ketoacidosis; DM: Diabetic Mellitus; HA1C: Gyrated Hemoglobin; IV: Intra Venous; NPH: Neutral Protamine Hagedorn; PH: Power of Hydrogen; SMBG: Self-Monitoring of Blood Glucose; UOG: University of Gondar; WHO: World Health Organization
Diabetes is a group of metabolic diseases characterized by persistently high level of glucose in the blood that occurs when the body cannot produce enough insulin or cannot use insulin [1,2]. Type 2diabetes is the one among the four clinical classes of diabetes, results from a progressive insulin secretory defect and peripheral tissue resistance to insulin. There may be some decrease in insulin production or a hyperinsulin state [1,3].
Prevalence of both type 1 and type 2 diabetic mellitus is increasing worldwide including our setting, type 2 Diabetes is rising much more rapidly, presumably because of increasing obesity, reduced activity levels as countries become more industrialized, and the aging of the population [4,5].
Diabetes of all types can lead to complications in many parts of the body and can increase the overall risk of dying prematurely. Possible complications include heart attack, stroke, kidney failure, leg amputation, vision loss and nerve damage. In pregnancy, poorly controlled diabetes increases the risk of fetal death and other complications [1,6,7].
Developing a more intensive educational strategies on self-care and medication adherence is key to achieving therapeutic goals in ambulatory care and reducing other potential risks,
which leads to the development of diabetes complications [8-10].
In this essay the name of the patient was replaced by MJ for the sake of confidentiality, so I will use this name MJ throughout this essay.
MJ is a 47 years old female known hypertensive patient for the last 2 years. She is admitted to the Medical Ward, University of Gondar (UoG) Comprehensive Specialized Referral Hospital for the diagnosis of newly diagnosed type two Diabetes mellitus (DM) with diabetic ketoacidosis precipitated by pyelonephritis. She was referred from other health center and presented with a compliant of excess urination and excess drinking started two months back. As she reported, her urination amount and pattern was approximately 4-5 liters per day with the frequency of 10-12 times per day and urge to drink water approximately 6-7 liters of water per day with the frequency of 8-10 times during the day time and 7-8 times during the night time associated with early satiety, dryness of lips and tongue and this is relieved after drinking water, shortness of breath associated with performing some activities, blurring of vision mostly during in the absence of light, intermittent headache on the right and left side of the
head, tingling sensation and numbness usually on the right side
of her arm, intermittent claudicating on her lower extremities
during walking relieved by rest, bilateral flank pain, burning
sensation during urination, one episode of projectile vomiting
of ingested matter on admission, high grade intermittent fever
with night sweating and fatigue, also she has epigasteric pain
with bleaching and bloating of the abdomen after she takes
meals prepared by berbere.
She has no history of delivery of a baby more than 4kg and the
presented clinical features described above. She has no personal
habits of such as alcohol consumption, cigarette smoking and
khat chewing. She had no family history of diabetic and cardiac
disease, but she had family history of hypertension (her father).
Diabetes is becoming a serious condition in the world, with
increased need for health care. The World Health Organization
(WHO) estimates that diabetes mellitus affects at least 285
million people and causes 3.2 million deaths, six deaths every
minute and 8700 deaths every day, and this figure will increase
by 70% in developed countries, and by 42% in developing
countries by 2030 [1,10,11].
The burden of diabetes has an impact not only on the quality
of life of affected individuals and their families, but also on the
country’s socioeconomic structure because of in low and middle
income countries, 29% of diabetes deaths occurs among people
under the age of 50, compared to 13% in high income countries
which are the active work forces [11-13].The main goal in
diabetes care is good quality of life, good metabolic control and
minimization of complications caused by diabetes. Diabetes is a
life-long challenge that needs behavioral change and adequate
self-care practices to keep the illness under control [1,2,4,14].
Management of diabetes focuses on relieving of symptoms,
prevention of acute and chronic complications, and Ensure
weight reduction in overweight and obese individuals, maintain
appropriate glycemic targets by applying best available
interventions and follow up care [2,4,6].
According to diabetic management guidelines, initial
fluid therapy in diabetic ketoacidosis (DKA) directed toward
expansion of the intravascular volume and restoration of renal
perfusion . Adequate rehydration with subsequent correction
of the hyperosmolar state may result in a more robust response
to low dose insulin therapy [15,16]. So, MJ was treated with
Initial fluid therapy (with a loading dose of two litters normal
saline and then the maintenance dose was followed) to replete
the extracellular fluid volume without inducing cerebral edema
due to rapid reduction in the plasma osmolality.
Almost all patients with DKA have a considerable potassium
deficit due to urinary and gastrointestinal losses. Most experts
recommended potassium repletion after an initial infusion of
isotonic saline to increase insulin responsiveness by lowering
the plasma osmolality and if serum potassium concentration
falls below 5.3meq/L [2,16].
Despite the standard’s diabetic management guidelines,
Insulin therapy lowers the serum glucose concentration by
decreasing hepatic glucose production rather than enhancing
peripheral utilization, diminishes ketone production by reducing
both lipolysis and glucagon secretion. As a result, any dose of
insulin that corrects the hyperglycemia will also normalize
ketone metabolism. A continuous intravenous infusion of
regular insulin is the treatment of choice, unless the episode
of DKA is uncomplicated and mild. After resolution of DKA,
patients treated with regular insulin received subcutaneous NPH
and regular insulin twice daily, whereas patients treated with
IV Glulisine insulin received Glargine once daily and glulisine
before meals [2,15,16]. So, MJ is currently on subcutaneous NPH
and regular insulin therapy.
Monitoring and target A1C (Gyrated hemoglobin), aim to
achieve normal or near normal glycaemia with an A1C goal
of <7 percent. More stringent goals (i.e., a normal A1C, <6.5
percent) can be considered in individual patients. Less stringent
treatment goals (e.g., <8 percent) may be appropriate for
patients with a history of severe hypoglycemia, patients with
limited life expectancies, older adults, and individuals with
comorbid conditions .
According to the American diabetic association standards
of medical care in diabetes, the A1C test should be performed
using a method that is certified by the National Glycohemoglobin
standardization program and standardized or traceable to the
Diabetes control and complications trial reference assay. Diabetic
HgbA1c is a good marker for glucose control, because the more
glucose is circulating in the blood, the more hemoglobin will be
glycated. However, once hemoglobin is glycated, it stays that way
until the red blood cell dies. Red blood cells live an average of
three to four months. That is why A1C level indicates an average
glucose over the last few months and as an example, A1C of 7.0%
means an average blood glucose level of 154mg/dl) . At that
moment MJ’s A1C level was not done, but I discussed with the
medical intern the benefit of monitoring the A1C level of MJ.
MJ’s serum glucose has been measured every hour, while
serum electrolytes, blood urea nitrogen, creatinine, osmolality,
and venous pH also measured every two to four hours.
Hypertension is a common problem in type 1 and especially in
type 2 diabetes. The American Diabetes Association recommends
measuring blood pressure at every routine diabetes visit .
Early and effective treatment of blood pressure is important,
both to prevent cardiovascular disease and to minimize the rate
of progression of diabetic nephropathy and retinopathy .
However, MJ is a known hypertensive patient on follow up and
her current blood pressure is 120/70mmhg.
The national standards on diabetic’s self-management and
education recommend and support all peoples with diabetics
should involve in diabetics self-management education and to
enhance knowledge attitude as well practice towards for quality
diabetic self-care .
For effective management of diabetes, patients must be
actively involved in self-care. This requires performance of many
complex self-care behaviors including dietary control, regular
exercise and psychosocial coping skills, medication adherence,
and self-monitoring of blood glucose (SMBG) [1,6,19]. Therefore,
I was trying to address MJ through counseling on exercise,
nutritional, behavioral and showing how to take the ordered
medication without interruption.
A review done by American Diabetes Association on
Dietary Carbohydrate (Amount and Type) in the prevention
and management of diabetes recommended the intake of diets
that contain carbohydrate with high fiber and low glycemic load
in order to reduce weight, controlling risk of coronary artery
disease (CAD) and other complications .
Similarly, a study supports foods that have low glycemic index
is important in mild glycemic control in diabetic patient. This
mechanism is beneficial as patient treated with pharmacologic
agent and also prevents increment of blood glucose level
after intake of foods . So, MJ was advised to reduce sugar
content diets (such as sweet fruit juices and honey) and to take
proportional amount of calorie intake (such as intake of whole
grains, vegetables, legumes, and dairy products) as well as the
negative effect of smoking and drinking much alcohol.
I advised MJ to perform regular exercises, that supported by
a standard management guideline of diabetics, to perform about
a minimum of 150 minute in a week that is 21minute exercise
per day mild to moderate aerobic physical far apart at least three
days and no more than two respective days without exercise
. Additionally, Diabetic patient without any problem would
be motivated to perform strenuous exercise in at least two times
per week .
The global diabetic care and America diabetic association
supports that psychosocial care should be associated with
a collaborative, patient approach method and provided to
all people with diabetes, with the goals of optimizing health
outcomes and health-related quality of life. Psychosocial
intervention is not limited to the illness it may incorporates total
quality of life in diabetics including behavioral, mood, attitude,
financial and emotional [1,18].
Psychosocial intervention is so important in improving
regimen of treatment adherence, glycemic control, psychological,
social welling and quality of life . So, MJ is reassured and
advised how to cope with her current anxiety and the social
discrimination she perceived.
Family and social support
Despite a systematic review on the role of family in
interventions among adults with diabetes, family should be
motivated on self-management up on blood glucose control
and other complications . MJ’s family advised to support
psychologically and other needs of MJ, because the family
dimension needs to be included to prove the effective family
Giving holistic care is the priority role of nurses, like that of
other chronic conditions rehabilitative care of diabetes demands
addressing the physical, social, economic and psychological
aspects of both the patients and the family. Because many
scholars agreed up on addressing these aspects for chronically
ill patients had greatest role in halting disease morbidity and
Developing nursing care plan on rehabilitative care of
diabetes, to identifying patient needs and intervene based on
the identified gaps should be our prior duty. So, intervention
based on evidence, with their rationale of giving that care by
incorporating patients/their family in decision making is the
corner stone of rehabilitative nursing care.
Since Diabetes is a chronic condition, most of diabetic
patients should have to improve their self-care practice and life
style in order to control the disease process and prevent the
The rehabilitation care should be given at all levels of health
care delivery system to improve lifelong quality of diabetic
patient, by preventing diabetic related burdens including social,
economic and psychological impacts of the disease .
Especially in developing countries like Ethiopia, late
diagnosis of disease, absence of care at primary health care
settings, lack of individualized glucose monitoring equipment’s and absence of efficient education schedules increase the burden
of the disease and its complication.
The study participant was informed about the purpose,
method, expected benefit, and risk of the study. She also
informed about her full right not to participate or withdraw
from the study at any time and deciding not to participate had no
impact on their services. Informed consent was obtained from
study participant and anonymity was employed to maintained
I would like to express my gratitude to the University Of
Gondar College Of Medicine and Health School of Nursing
Department of Medical Nursing, for their Permission and the
study participants for their valuable information.