• those who show signs and symptoms of diabetes but have normal fasting blood glucose levels
• those who have risk factors for diabetes but have normal fasting blood glucose levels
• those who have complications usually associated with diabetes.

After the patient fasts for 8 hours, a blood sample is obtained by venipuncture. Next, the patient drinks 75 to 100 grams of glucose. Then additional blood samples are obtained at 30 minute to 60 minute intervals for 2 hours.

The results of an oral glucose tolerance test are normal if the initial fasting blood glucose level is 70 to 115 mgjdl, the final 2-hour glucose level is less than 125 mgjdl, and all glucose values in between are less than 200 mgjdl. Despite two normal fasting blood glucose test results, a physician can diagnose diabetes in a nonpregnant adult who has an oral glucose tolerance test in which the 2-hour plasma glucose level is 200 mgjdl or more.

The 2-hour oral glucose tolerance test isn’t used to monitor a patient’s diabetes treatment. However, it can be used to monitor patients who have impaired glucose tolerance and who are at risk for developing diabetes later in life. Despite a normal fasting glucose test result, a physician can diagnose a patient with impaired glucose tolerance if the 2-hour glucose level is 140 to 200 mgjdl.

Nursing considerations

When preparing your patient for a 2-hour oral glucose tolerance test, instruct her to maintain a normal diet and activity level for 3 days before the test. Failure to do so may interfere with the test results. Some drugs such as diuretics, nicotinic acid, and betablockers may also interfere with test results. High doses of some hormones can affect the results, as well. When possible, the patient’s physician will discontinue these drugs for 3 days before the test.

The patient will need to fast for 8 hours before the test. Try to schedule it for the morning so that most of the fasting time will occur while she’s sleeping.

Instruct your patient to drink the glucose solution within 5 minutes. During the 2 hours required for the test, the patient should remain seated and not smoke.

Hypoglycemia probably won’t occur after a glucose load has been administered to a patient suspected of having diabetes, but it could occur if the patient has another unsuspected disorder, such as islet cell tumors. If the patient develops signs and symptoms of hypoglycemia, draw a blood sample for confirmation. If the patient is hypoglycemic, stop the test immediately and provide the appropriate treatment.

Send all samples to the laboratory immediately or refrigerate them to prevent altered test results.

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Nursing considerations

Send venipuncture samples to the laboratory immediately or refrigerate them to prevent altered test results.
Interpret self-monitoring and laboratory test results in light of your patient’s food intake, activity level, and emotional state during the hours immediately before the test. Always recheck unusual results or sudden deviations from the patient’s normal blood glucose pattern.
To encourage frequent self-monitoring, tell your patient that maintaining glucose levels as near to normal as possible can slow the progression of long-term microvascular complications – retinopathy and nephropathy. Periodically check your patient’s self-monitoring technique and her meter.
If your patient’s blood glucose levels remain abnormally high, she may need more frequent blood glucose measurements. If a pattern emerges, such as abnormally high blood glucose levels before dinner, changes in your patient’s daily treatment plan may be necessary.

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Lipid profiles of patients with Type 2 diabetes commonly show increased total cholesterol, LDL cholesterol, and triglyceride levels and decreased HDL cholesterol levels. A high LDL cholesterollevel increases the risk of CAD, whereas a high HDL cholesterol level decreases the risk. High triglyceride and total cholesterol levels also increase the risk of CAD.

If the test detects a lipid abnormality, teach your patient about the need for lifestyle changes, such as a low-fat diet and an exercise program. Her physician may prescribe an antilipemic drug, such as simvastatin or fluvastatin. Patients taking such drugs should have a fasting lipid profile at least once a year.

Effective therapy should lower LDL choles­terollevels in patients with diabetes to less than 130 mgjdl and raise HDL cholesterol levels to more than 35 mgjdl in men and more than 45 mg/dl in women (normal HDL cholesterol levels are more than 45 mgjdl in men and more than 55 mg/dl in women). If your patient has already been diagnosed with CAD, her LDL cholesterol levels should be lowered to 100 mgjdl, and her triglyceride levels should be lowered to 190 mgjdl.

Nursing Considerations

Instruct your patient to fast for 12 hours before the test. She should avoid vigorous exercise the day before the test and shouldn’t alter her diet before the fast begins. Also, instruct her to avoid alcohol for 24 hours before the test because it may falsely elevate triglyceride levels. If possible, your patient’s physician will withhold drugs that may alter cholesterol or triglyceride levels.

Before drawing blood for a fasting lipid profile, determine if your patient has a fever or has had surgery or trauma recently. These conditions may interfere with the test results. If you note such a condition, reschedule the test.

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Nursing Considerations

Reassure your patient that an ECG doesn’t hurt or cause an electric

shock. Some preparation may be needed before applying the electrodes to her skin. For example, if she has been sweating, the sites should be dried. If a patient has a lot of hair at the electrode sites, you may need to shave them to provide better contact.

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Glucosuria

• aminosalicylic acid
• ascorbic acid
• cephalosporins
• chloral hydrate
• chloramphenicol
• isoniazid
• levodopa
• methyldopa
• nalidixic acid
• nitrofurantoin
• penicillin G (large doses)
• phenazopyridine
• probenecid
• salicylates (large doses)
• streptomycin
• tetracyclines

Ketonuria

• levodopa
• phenazopyridine
• phenolsulfonphthalein
• phenothiazines
• salicylates
• sulfobromophthalein

Proteinuria

• acetazolamide
• aminosalicylic acid
• cephalothin (large doses)
• nafcillin
• sodium bicarbonate
• tolbutamide
• tolmetin

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Assessing The Patient

Begin by assessing your patient’s feet for abnormalities such as corns or bunions, which increase the risk of ulceration. Ask her how she cares for her feet.

Next, assess your patient for risk factors. If she has a history of diabetic neuropathy or peripheral vascular disease, she’s at greatest risk for developing a foot ulcer. Unfortunately, the development of a foot ulcer may be the first sign that your patient has neuropathy or peripheral vascular disease.

Implementing The Plan

If your patient has no history of neuropathy or peripheral vascular disease and her foot assessment reveals no abnormalities, focus on correcting any misconceptions she may have about foot care. Then, instruct her in a daily foot care routine, which should include keeping her feet clean and dry, examining her feet for blisters, and wearing comfortable shoes. Also, advise your patient to have her feet examined by a physician at least once a year.

If your patient has calluses or corns, teach her how to manage the condition with an emery board, callus file, or pumice stone. Tell her that cutting calluses or corns off her feet or using an over-the­counter medicated pad to treat them may cause an ulcer to form. If your patient’s calluses or corns are caused by abnormally high or low arches, refer her to a specialist. Other abnormalities, such as hammer toes and metatarsal deformities, may require special shoes, regular care by a podiatrist, or surgical repair of the deformity.

If your patient already has a foot ulcer, your plan of care will include treating the ulcer and determining what caused it. Depending on the type of ulcer and its location, treatment may include the following:

• removal of the cause (for example, poor-fitting shoes)
• a restriction on weight-bearing activities, if the ulcer is on the plantar of the foot
• wound care to heal the ulcer
• infection control, including antibiotic therapy
• follow-up care.

To help prevent another ulcer, you should also review your patient’s knowledge and her compliance with routine foot care.

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