Assessing the Diabetic Patient
Assessing the Diabetic Patient
Rhonda M. Jones, Pharm.D.
Camene E. Wilson, B.S., Pharm.D.
Diabetes Mellitus is a very complex disease that has an impact on a
large portion of our society. Approximately 16 million individuals in the United States,
6% of the population, are affected by diabetes mellitus. 1 Type II or non-insulin-dependent (NIDDM) is by far the most prevalent of the two
types of diabetes, with 90% of diabetic patients falling into this category. 1
Currently, diabetes mellitus ranks in the top five leading causes of death in the U.S. In
addition, the estimated total economic cost of this disease for 1992 was nearly $92
billion. 2 Since diabetic patients routinely visit their local pharmacy for medications and supplies, the community pharmacist has a great opportunity to assess the diabetic patient. Through the patient assessment process, the pharmacist can identify, resolve and prevent drug-related and disease-related problems that adversely affect the care of the diabetic patient. This article will review various techniques that the pharmacist may incorporate into his/her
practice setting to assess the diabetic patient.
The Assessment Process
Patient assessment can be defined as a systematic process of
acquiring, interpreting and analyzing subjective and objective patient information to
identify, resolve and prevent drug-related and disease-related problems. In order to
assess thoroughly the diabetic patient, the pharmacist should obtain the following: past
and current health history; medication history (both prescription and nonprescription);
medication side effects; information regarding hypoglycemic and hyperglycemic reactions;
glucose monitoring data; diet and exercise history; information about the patients
foot care and diabetes complications.
Drug Regimen Review: After obtaining the patients
past health history, current health status and medication history, the pharmacist should
review the patients medication profile. During this review, the pharmacist should
assess the following: 3 correlation between drug therapy and medical problems; appropriate drug selection; appropriate
medication dose; medication compliance; drug-disease or drug-drug interactions; medication
side effects; drug allergies; and patient knowledge of drug therapy. With the
pharmacists unique pharmaceutical knowledge base, he/she is able to identify
therapeutic issues not recognized by other disciplines.
Glucose Control: There are two major goals of management of
the type II diabetic patient:
Therefore, evaluating glucose control is very important. To assess
glucose control, the pharmacist should review the patients blood glucose values.
Goal plasma glucose levels have been established by the American Diabetes Association and
are listed in table 1. 5 If the patients
glucose values are not within the goal range, the pharmacist must inquire as to the cause
of the high or low value(s). The effects of the patients diet, exercise and
medication regimen must all be reviewed. Common prescription drugs that interfere with
blood glucose are listed in table 2. It is also important to ask questions about over-the-counter medication use to
identify potential problems in blood glucose regulation (e.g., medications containing
sugar such as bulking agents or cough syrup).
- to achieve normal glucose control and
- prevent diabetic complications. 4
|Preprandial glucose (mg/dL)
|Bedtime glucose (mg/dL)
|Achieving near-normal blood glucose levels in patients
with diabetes requires comprehensive training in self-management. 5 Such programs should include the following components according to individual
patient needs: frequent self-monitoring of blood glucose; meticulous attention to meal
planning; regular exercise; physiologically based insulin regimens or oral
glucose-lowering agents in type II diabetic patients; instruction in the prevention and
treatment of hypoglycemia; instruction in the prevention and treatment of diabetic
|Medications that Interfere with Blood Sugar
- Glucocorticoids Niacin
- Oral contraceptives
- Beta adrenergic antagonists
- Salicylates (high doses)
Hypoglycemia and Hyperglycemia: When assessing the diabetic
patient, the pharmacist should also ask questions pertaining to signs and symptoms of
hypoglycemia and hyperglycemia. Typical hypoglycemic symptoms include: palpitations,
nervousness, shakiness, sweating, hunger and irritability (Table 3). Signs and
symptoms of hyperglycemia include polyuria, polydypsia, polyphagia, vision changes and
fatigue (Table 4). If the patient complains of these symptoms, it is important to determine the
relationship between the patients food consumption, medication schedule and exercise
regimen. For example, the patient may have missed a meal or exercised more than usual
which, in turn, may have caused a hypoglycemic reaction.
|Symptoms of Hypoglycemia
- Night Sweats
- Visual Disturbances
The pharmacist should also determine if the patient
is recognizing and treating hypoglycemic reactions appropriately. The patient needs to be
aware of appropriate foods that will quickly return the glucose level to normal (e.g.,
fruit juice, sugar cubes or glucose tablets). 4
|Symptoms of Hyperglycemia
- Vision changes
- Poor wound healing
- Dry or itchy skin
Diabetic Complications 1,4,5
It is important for the pharmacist to ask the patient questions
that can help detect the occurrence of diabetes complications. These complications include
retinopathy, nephropathy, neuropathy and coronary artery disease. To help pharmacists
identify possible eye complications, they can ask the patient if he or she has experienced
any vision changes. However, because of eye fluid changes that occur when better glucose
control is achieved, blurred vision can occur when diabetic medication is initiated.
Vision changes may also occur with hyperglycemia and hypoglycemia. It should be emphasized
to the patient that diabetic retinopathy is usually asymptomatic until it is severe.
Therefore, it is recommended that diabetic patients have a complete eye and visual exam
including full dilation of pupils by an ophthalmologist at least annually. 5
In diabetic patients, there are a number of conditions that either
precipitate impairment of renal function or exacerbate the condition when present. These
conditions include hypertension, infections, neurogenic bladder, urinary obstruction and
nephrotoxic drugs. To assess renal complications, the pharmacist should evaluate the
patients blood pressure, inquire about symptoms of urinary tract infections (i.e.,
dysuria, hematuria or frequency) and a neurogenic bladder (i.e., decreased frequency of
urination, urgency, dribbling or inability to void). 5 Nephrotoxic drugs, chronic analgesic abuse and dye contrast radiographic studies
have been associated with increased incidence and acceleration of renal failure in
patients with diabetes. 4 This information suggests that nephrotoxic drugs and chronic analgesic use should be avoided in the diabetic patients.
Diabetes can also cause nerve-related problems, or diabetic
neuropathy. The pharmacist can inquire about sensory neuropathies, autonomic neuropathies
and amyotrophy. Sensory neuropathies present as numbness, tingling and feeling of cold and
pain usually in the legs and feet. Autonomic neuropathies cause sexual dysfunction,
impaired motility of the gastrointestinal tract, neurogenic bladder and orthostatic
hypotension. 6 The patient may
complain of diarrhea, particularly after meals and at night, or nausea and abdominal
discomfort due to delayed emptying of gastric contents. A neurogenic bladder is usually
characterized by a gradual loss of the ability to void. Patients with orthostatic
hypotension will usually complain of sudden dizziness or lightheadedness after standing up
quickly. Amyotrophy, a condition causing muscle wasting, presents as thigh pain or
difficulty in rising from a sitting position. 6 It is important to recognize diabetic neuropathies early because with physical
therapy, drug treatment and improved glucose control, the patients quality of life
often can be improved.
Diabetic foot problems are due to peripheral neuropathy,
peripheral vascular disease, superimposed infection or a combination of these
complications. The key component in managing foot problems is prevention, which requires
proper foot care by the patient, early detection and prompt treatment of lesions. TABLE 5 lists many
warning signs and symptoms of diabetic foot problems. To help detect possible foot
problems, the pharmacist should ask the patient specific questions such as: Do you have
burning or tingling sensation in your feet? Do you have cold feet? Do you have bunions,
corns, or calluses on your feet? Do you have chronic scaling, itching, or dry feet? Do you
have any sores on your feet or infections that wont heal? The pharmacist can also
play a key role in teaching the patient proper foot care.
Diabetic Foot Disorders
- Cold feet
- Burning, tingling, or crawling sensations
- Weakness of one foot (drop foot)
- Gradual change in foot shape
- Painful or painless wounds
- Slow-healing or nonhealing wounds
- Skin color changes (cyanosis, redness)
- Chronic scaling, itching or dry feet
- Recurrent infections (e.g., athletes foot)
Once the pharmacist has obtained the necessary patient information,
possible drug-related or disease-related problems can be identified. The pharmacists
intervention to correct the problem will vary according to the problem. An intervention
may include one or more of the following: educating the patient, recommending an OTC
product, contacting the patients physician or referring the patient to his/her
physician or another health-care professional for follow-up.
Diabetes mellitus is a very complex disease that affects many
individuals across the country. Pharmacists can play a crucial role in assessing the
diabetic patient due to their frequency of contact with the diabetic patient. The
assessment process involves not only reviewing the patients past and current health
status, glucose control and medication, diet and exercise regimen, but also identifying
possible warning signs and symptoms of diabetic complications.
For more information, see The American Diabetes Associations
position statement: Standards of Medical Care for Patients with Diabetes Mellitus.
Diabetes Care. 1994;17:616-623. Related materials are available from the American Diabetes
1. Davidson MB. Diabetes Mellitus: Diagnosis and Treatment. 3rd ed. New York, NY: Churchill Livingstone Inc.;1991;ix:293-327.
2. Ray NF, Wills S, Thamer M, Medical Technology and Practice Patterns Institute. Direct and Indirect Costs of Diabetes in the United States in 1992. American Diabetes Association, Alexandria, VA; 1993.
3. Shrimp LA, Mason NA. Constructing a patientís drug therapy problem list. Bethesda, MD: American Society of Hospital Pharmacists, Inc.;1993:7.
4. American Diabetes Association. Physicianís guide to non-insulin-dependent (type II) diabetes: diagnosis and treatment. 2nd. ed. Alexandria, VA:American Diabetes Association, Inc.;1988:65-76.
5. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 1994;17(6):616-623.
6. Koda-Kimble MA, Young LY. Applied Therapeutics: The Clinical Use of Drugs. 6th ed. Vancouver, WA: Applied Therapeutics, Inc.; 1995;48:1-6.