Educational
program for people
with diabetes
5
Diabetic Ketoacidosis
Long term complications
Sexuality
Footcare
Inv.: 1-6-14735 (Hôtel-Dieu, Hôpital Fleurimont)
BIBLIOGRAPHY
TEACHING PROGRAM FOR DIABETICS. Centre hospitalier
universitaire de Sherbrooke, 2004.
CENTRE DE JOUR DU DIABETES DE L’ESTRIE. Mieux connaître
le diabète, Centre hospitalier universitaire de Sherbrooke, 2002,
121 p.
UNITÉ D’ENSEIGNEMENT ET DE TRAITEMENT
DIABÉTIQUES, Session éducative sur le diabète,
universitaire de santé de l’Estrie, 1999, 57 p.
Version revised by members of the Centre de jour du diabète de l’Estrie
team :
Josée Arbour, nutritionist
France Bégin, pharmacist
Suzanne Buteau, nurse BSC
Josée Desharnais, clinician nurse
Catherine Goulet-Delorme, clinician nurse
Julie Dubé, nutritionist
Dre Chantal Godin, endocrinologist
Dre Ghislaine Houde, endocrinologist
Élisabeth Turgeon, kinesiologist
UNITÉ DE JOUR DU DIABÈTE DE L’HÔTEL-DIEU DU CHUM,
Understand your diabetes and live a healthy life !, 7e éd., Centre
hospitalier de l’Université de Montréal, 2009, 299 p.
PROGRAMME-CLIENTÈLE DIABÈTE. Mieux connaître votre
diabète, Enseignement de base (clientèle adulte), Complexe
hospitalier de la Sagamie, brochures # 321-1-7, 2002.
MEDISENSE ABBOTT. Les cétones et la gestion du diabète
(brochure), MediSense Abbott, 2000.
Centre hospitalier
www.chus.qc.ca
universitaire
We also wish to acknowledge the contribution of all authors of
previous editions.
August 2011 (revised) – Centre hospitalier universitaire de Sherbrooke
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POUR
Centre
Page 27
de
Sherbrooke
website
:
TABLE OF CONTENTS
PROTECTION
WHY IT IS IMPORTANT TO TREAT DIABETES ......................... 5
Choice of footwear
♦
Choose closed shoes, with low to medium
heels, made of leather or fabric, sufficiently
wide and deep to avoid having the shoe rub on
the top of the toes. Do not buy shoes that
could cause injury (e.g.: seams, shoes that are
too pointed...);
♦
♦
When purchasing them, the shoes must be
comfortable and adapted to your feet. Buy
them in the afternoon or at the end of the
day (your feet are often swollen) and break
them gradually (1 hour the first day, 2
hours the second day...);
Avoid walking barefoot; wear slippers when you
are at home, beach sandals and shoes that
completely protect your feet for physical activities;
♦
Protect your feet from direct cold and heat
(avoid heating pads or hot water bottles).
KETOACIDOSIS (TYPE 1 DIABETES) ........................................ 6
Symptoms................................................................................ 6
Detection ................................................................................. 7
What should you do?............................................................... 9
LONG-TERM COMPLICATIONS ............................................... 10
Retinopathy ........................................................................... 13
Nephropathy .......................................................................... 14
Cardiovascular disease ......................................................... 15
Neuropathies (feet and other systems) ................................. 16
SEXUALITY ................................................................................. 18
FOOT CARE ................................................................................ 22
Hygiene / examination ........................................................... 22
Corns or calluses................................................................... 23
Nails....................................................................................... 24
Lesions .................................................................................. 25
Protection .............................................................................. 26
BIBLIOGRAPHY .......................................................................... 27
Remember! These few hygiene, prevention and protection measures
for your feet could make a huge difference in your quality of life.
Page 26
Page 3
Regular visits to your doctor are
necessary to control your diabetes properly
and avoid complications.
• Never use an object that could hurt
your feet (scissors with pointed ends,
nail clippers, blades, knives, etc...);
• If you don’t see well, have someone
help you;
• Clean you material after use;
• If your nails are broken, brittle, thick or
if there is infection around the nail
(ingrown toenail), see your doctor or
your foot care specialist.
LESIONS
If you notice a wound or a blister:
DO NOT PUNCTURE THE BLISTER.
Clean it with soap and water; do not use alcohol or colored products.
Watch the wound to detect any sign of infection such as pain,
swelling, heat or the presence of pus. Immediately consult the
doctor if the wound does not heal or if you notice any of these signs.
Page 4
Page 25
WHY IT IS IMPORTANT TO
TREAT DIABETES?
How do I treat this?
♦
Delicately smooth calluses hardened, thickened skin with a
dampened pumice stone after a shower or bath;
♦
The advantages of treating your diabetes are to :
♦
Improve your quality of life;
♦
Apply a cream specifically for the care of calluses; repeat for
several days;
♦
Use only non-adhesive and non-medicated protective plasters to
care for the corn;
♦
Avoid the side-effects of abnormal blood glucose level, that is too
high (hyperglycemia*) or too low (hypoglycemia*);
♦
Never use products that contain chemical substances; they could
cause burns;
♦
Avoid ketoacidosis and hyperosmolar coma.
♦
Never cut the corn or calluses;
♦
Do not scrape corns with your fingernails because this could
cause infection;
♦
♦
Speak to a nurse or a podiatrist, if necessary. If you want to find
information about foot care nurses, you can consult the website of
the Association des infirmières et infirmières en soins de pieds du
Québec at www.aiispq.org or call them at 1-800-771-9664.
Reduce your risks of developing long term health problems.
To do this, you must:
-
Reach and maintain blood sugar levels as close as possible to
a normal reading, for as long a period of time as possible;
-
Adopt healthy lifestyle habits (eating, physical activity, weight
control, stress management);
-
Eliminate anything which harms your health (e.g.: smoking,
etc.);
-
Follow your treatment for diabetes and associated conditions
(cholesterol, high blood pressure, etc.) as recommended;
-
Meet with your doctor regularly.
NAILS
♦
♦
Nails that are too long, too short or improperly
cut can cause injury and become infected;
After your bath, file your nails with an emery
board always in the same direction, rounding
the corners. (This file must be used on toenails
only and be changed frequently);
Page 24
*
You will find more information about hypoglycemia and
hyperglycemia in Booklet 4.
Page 5
KETOACIDOCSIS (TYPE 1 DIABETES)
What are ketones?
If there is not enough glucose to feed the cells or if there is not
enough insulin to make the glucose enter the cells, the body begins
to transform fats for the energy they contain. This brings about the
production of ketones, acid chemical substances, which are harmful
to the body if they are in large quantities. The ketones circulate in the
blood, are partially filtered by the kidneys and are excreted in the
urine.
Dry your feet well, particularly between and
under the toes; humidity promotes maceration
of the skin and infections (called athlete’s foot).
Apply a hydrating cream, except between the
toes, to avoid dry skin.
What is ketoacidosis?
Ketoacidosis is a dangerous accumulation of ketones in the blood
secondary to a lack of insulin. It must be treated immediately.
Inspect your feet daily using a mirror and check : color, warmth,
friction areas, soles of the feet, spaces between the toes, toenails…
Ketoacidosis = extremely unbalanced diabetes
SYMPTOMS
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
Thirst;
Increase in the frequency of urination;
Headaches;
Blurred vision;
Nausea, vomiting;
Abdominal pain;
Dizziness;
Acceleration in the pulse;
Difficulty in breathing;
Shortness of breath;
Fruity breath (bad taste in the mouth);
Often associated with rapid loss of weight.
Page 6
Ask your doctor to examine your feet at least
once a year or more often if necessary to detect
any change.
CORNS AND CALLUSES
Corns (often on the toes) are caused by the shoe rubbing against
the skin.
An excess of thickened, hardened skin (callus, often under the
foot) compresses the skin and may cause lesions.
Page 23
FOOT CARE
DETECTION
Keep your feet healthy. This is a
necessity in daily life. There are
all kinds of ways of hurting your
feet, and any wound, no matter
how small, could have serious
consequences. These risks are
even more serious if :
♦
♦
♦
♦
Detection is done by testing the urine or blood (taken from a
fingertip).
In urine
ketonuria
Method (Ketostix)
=
♦
You have been diabetic for a long time (over 10 years);
You are older than 65 years old;
You have problems related to blood circulation;
You are less sensitive to pain or heat.
♦
♦
You must not wait for these problems to develop, which can happen
slowly and often without your even realizing that something is a
miss, before taking preventive measures.
♦
♦
HYGIENE / EXAMINATION
Wash your feet daily with lukewarm water and mild soap; avoid
taking long baths (ideally less than 10 minutes).
♦
Check the water temperature with the wrist or elbow.
In the blood
ketonemia
Page 22
♦
=
Page 7
Dip the Ketostix strip in a
sample jar containing urine or
directly in the stream of urine;
Wait for 15 seconds;
Compare the color of the strip
with those printed on the
container ;
Write the result, time and date
in the blood glucose logbook
you keep;
Close the strip container
immediately. Throw away the
container 4 months after it was
opened.
With a blood glucose meter
(Precision Xtra);
The same procedure as for
taking your blood glucose
reading, but use the special
strips for ketones (blood
ketones).
When should you check for ketones?
♦
When blood sugar levels remain higher than 17 mmol/L, when
you are NOT sick;
♦
During episodes of vomiting or diarrhea, no matter what the
blood glucose level is;
♦
When you are sick (cold, infection, hospitalization);
♦
General advice to help you prevent difficulties and maintain an
active sex life:
♦
Keep diabetes under control;
♦
Adapt yourself as best you can to the limitations posed by your
diabetes;
♦
Adopt good lifestyle habits;
♦
Avoid smoking and alcohol;
♦
Give yourself pleasurable moments.
During pregnancy (if you have type 1 diabetes).
TEST 4 TIMES A DAY
IF YOUR DIABETES IS UNSTABLE
OR IF YOU ARE SICK
Page 8
Page 21
Men with diabetes
WHAT SHOULD YOU DO?
See the following table for what you should do, depending on the
results for the urine or blood ketones.
PROBLEMS
More frequent yeast
infections (balanitis)
SYMPTOMS
TREATMENT
Redness at the tip of the
penis
Cream or pills prescribed
by the doctor
Burning sensation when
urinating
Better control of blood
glucose levels
Urine ketone
level
Blood ketone
level
Advice
Average to high
More than 3
mmol/L
You need emergency treatment
immediately. Consult a doctor.
Pain upon intercourse
Erectile disorder:
Whether or not
associated with diabetes
Difficulty in having or
maintain an erection
Of various origins
(anxiety, medication,
vascular or neurological
problems, smoking,
alcoholism)
See your doctor to identify
the cause and treatments
(medication, external
erection, pump, penis
implant, etc.)
Seek professional help if
necessary (psychologist,
sex therapist).
Low
Trace
Negative
You are at risk of developing
From 1.5 to 3 ketoacidosis. Call the diabetes
mmol/L
care team or consult a doctor
without delay.
From 0.6 to
1.5 mmol/L
Redo the blood glucose and urine
ketone test in 2 to 4 hours.
Less than 0.6
No action necessary.
mmol/L
It may be necessary to increase the insulin doses, as you have been
taught, if you know how to do this.
Prevention :
Avoid excessive drinking or smoking that could cause vascular or
neurological problems and interfere with the erection mechanism.
Page 20
For persons with type 2 diabetes, ketoacidosis is extremely rare
because the amount of insulin secreted by the pancreas is usually
sufficient to prevent the formation of ketones. However, blood
glucose levels could rise during illness to very high levels,
particularly during a severe infection, and especially if the person
who is diabetic is not able to hydrate himself adequately. Blood
sugar levels will then be very high and could cause changes in
consciousness (hyperglycemic hyperosmolar coma).
Page 9
LONG-TERM COMPLICATIONS
DID YOU KNOW THAT PROLONGED HYPERGLYCEMIA
(OVER SEVERAL YEARS)
Women with diabetes
INCREASES THE RISK OF
LONG-TERM COMPLICATIONS ?
PROBLEMS
SYMPTOMS
TREATMENT
Decrease in vaginal
lubrication
Irritation or pain upon
penetration
To discuss with your doctor
Sterile lubricant sold at the
pharmacy (e.g.: Wet, Replens)
Do not use vaseline.
RETINOPATHY
(EYE)
NEPHROPATHY
More frequent vaginal
infections (yeast
infections)
(KIDNEYS)
Itching and redness in
Cream, tablets or vaginal
suppositories prescribed by your
the vulva area.
doctor or suggested by your
Pain during intercourse
pharmacist
Thick, white-ish vaginal Better control of blood glucose.
discharge.
CARDIOVASCULAR DISEASE
(HEART)
Prevention :
♦
NEUROPATHIES
(feet and other systems)
♦
(FOOT)
♦
RESEARCH PROVES IT!
♦
♦
Page 10
Maintain good personal hygiene and use a mild soap (e.g.:
Dove);
Use unscented products (tampons, sanitary napkins, toilet paper,
etc.);
Avoid bubble bath and bath oils;
Wear cotton underclothing rather than those made of synthetics
(nylon); they absorb humidity better, thereby decreasing the risk
of yeast infections;
Avoid wearing pants that are too tight.
Page 19
SEXUALITY
Can diabetes affect your sex life?
Many people with diabetes have a very satisfactory sex life.
How-ever, certain difficulties may be encountered by others. It is,
there-fore, important for both men and women to talk about these
difficulties.
If you feel weakness, fatigue or any other
symptom related to hypoglycemia or
hyperglycemia, you will probably not
have
much
interest
in
sexual
relationships. But if you are able to
maintain your blood glucose level near
normal,
any
physical
discomfort
associated with poor control of blood
sugar levels will disappear and your
interest in sex could thus be revived.
Maintaining good control over diabetes is therefore an
important factor in maintaining an active sex life. This is another
advantage to keeping your diabetes well under control.
LONG-TERM COMPLICATIONS
In this part of the booklet, you will learn about different
complications that can arise as the result of prolonged
hyperglycemia. A short description of each complication and its
manifestations will be explained. We invite you to talk to your
doctor about the ways of avoiding these complications or lessening
their severity.
ARE LONG TERM COMPLICATIONS ALWAYS VERY SERIOUS?
No, because we can slow the progression of complications when
they are detected in time. It is also possible to prevent them in the
first place.
Stopping smoking is most important in preventing complications.
The combination of diabetes and smoking spells trouble for your
health. Smoking significantly increases the risk of developing
long-term complications of diabetes. It is not easy to stop smoking
but many smokers succeed after several attempts. The important
thing is to keep trying to quit. Various methods of support are
available :
Quit Smoking Centers in your CSSS
Quitnow helpline (1-866-JARRETE or 1-866-527-7383).
The following parts of your body may be affected:
1. Eye (retinopathy)
2. Kidneys (nephropathy)
3. Heart and blood vessels (cardiovascular disease)
4. Nervous system (neuropathy) = feet, bladder, digestion,
sexuality, etc.
Page 18
Page 11
Certain measures can be taken to decrease the risk to all
complications :
♦
♦
♦
♦
Signs of nerve damage :
Maintain your blood glucose level at as near normal a level as
possible;
Manage high blood pressure;
Manage your cholesterol level (diet and medication);
Stop smoking.
FEET
Numbness, tingling;
Burning sensation;
Decrease in sensitivity (heat, cold, pain).
DIGESTION
Bloating, regurgitation (stomach);
Constipation, diarrhea (intestines).
BLADDER
Frequent urination in small amounts or urinary
retention;
Urinary infections.
SEXUALITY
OTHER
Decrease in the ability to have or maintain an
erection;
Decrease in vaginal lubrication.
Disappearance of symptoms of hypoglycemia;
Hypotension (low blood pressure) when changing
position.
How can neuropathies be prevented?
•
•
•
•
Take care of your feet every day;
Watch out for pain, swelling or lesions that do not heal;
Ask your doctor to examine your feet at least once a year;
See a doctor right away if you have a wound.
How are they treated?
Your doctor will be able to advise you about how to lessen pain in
your feet (medication, creams) or deal with other symptoms affecting
the digestion, elimination and sexual problems.
Page 12
Page 17
How can you prevent cardiovascular diseases?
♦
♦
♦
Practise physical activity regularly;
Aim for a healthy weight;
See your doctor if you have pain in the chest or breathlessness,
cramps when walking, or a change of color in your toes.
How is it treated?
♦
♦
♦
By a healthy lifestyle (diet, physical activity, stress management);
By medications (cholesterol, hypertension, circulation);
By medical interventions (dilatation, bypass, surgery).
RETINOPATHY
What is retinopathy?
The retina (the sensitive membrane at the back of the eye) is
covered with tiny blood vessels that carry blood to the cells. In
retinopathy, the retina slowly deteriorates and as it does do, it loses
its characteristics. This is caused by prolonged hyperglycemia in
which the tiny blood vessels in the eye are broken or obstructed.
Tiny hemorrhages can occur and you could lose part of your vision.
How can this be prevented?
♦
NEUROPATHIES
(Feet and other systems)
♦
Report any change in vision to your doctor;
Have an optometrist or ophthalmologist examine the retina
depending on their recommendation. (Every year or 2 years).
What are neuropathies?
How is it treated?
The nerves conduct electricity (neural impulses) throughout your
body. They may be damaged by prolonged hyperglycemia. The
transmission of information (through neural impulses) becomes more
difficult. Neuropathy affects primarily the extremities (the feet) but
may also affect the internal organs (the intestine, stomach, bladder
and sexual function).
Page 16
♦
♦
♦
Only an ophthalmologist can treat this problem;
Retinopathy can be treated with a laser treatment;
You must realize that the treatment is a only a palliative measure
and the retinopathy may progress if the diabetes is not well
controlled.
Page 13
NEPHROPATHY
CARDIOVASCULAR DISEASE
What is nephropathy?
What is cardiovascular disease?
The kidneys can be readily compared to a filter. When
hyperglycemia is prolonged, the filter is damaged and allows
important elements, proteins, to pass into the urine. The amount of
protein found in the urine is related to the severity of damage to the
kidney. Significant deterioration in renal function may require dialysis
treatments.
Prolonged hyperglycemia may damage the major blood vessels (the
arteries) causing hardening of the arteries and promoting deposits
(atherosclerotic plaque). Over time, the arteries shrink and
obstructions develop. The heart must therefore work harder to pump
blood.
This carries a greater risk of:
How can you prevent nephropathy?
♦
♦
A urine analysis will be done at least once a year to detect the
presence of microalbuminuria (proteins in the urine).
♦
♦
♦
♦
Heart attacks;
Paralysis or stroke (CVA);
Hypertension (high blood pressure);
Circulatory impairment;
Sexual problems (decrease in erection).
How is it treated?
♦
♦
♦
If there is an abnormal quantity of proteins (microalbuminuria) in
the urine, your doctor will prescribe medication that will decrease
the excretion of proteins;
Strict control of arterial hypertension (high blood pressure);
A low-salt (sodium) and low-protein diet may be helpful.
Signs of difficulty
♦
♦
♦
♦
♦
Page 14
Chest pain accompanying any exertion;
Pain in the calf when walking or going up stairs;
Slow healing of wounds of the lower members;
Abnormal colouring of the extremities;
There may be no symptoms, the disease may be detected during
a resting or stress electrocardiogram.
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