Instruct your patient and her family to notify her physician immediately if signs or symptoms of rejection or infection develop or if they can’t obtain the prescribed drug. Make sure they know the signs and symptoms of rejection: temperature over 100° F, weight gain of 2 to 3 pounds in 1 day, increased blood pressure, pain, swelling or tenderness over either graft site, and hyperglycemia.

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Any patient who’s using insulin or taking an oral antidiabetic drug should consume alcohol only with a meal. Alcohol and certain sulfonylureas may cause a disulfiram-like reaction, flushing, headache, nausea, and breathlessness. Alcohol and metformin can increase the risk of lactic acidosis.

Because alcohol inhibits gluconeogenesis, a patient with diabetes must watch carefully for hypoglycemia when she consumes alcohol. When she’s fasting, or when glycogen stores are depleted, her body can’t make glucose from noncarbohydrate sources, such as fat and protein. So, when blood glucose levels begin to drop, the normal compensatory mechanism of converting stored energy into glucose is blocked by the alcohol. The result is hypoglycemia.

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1. Check the serving size. Note that a % cup serving is much less than most adults eat.
2. Check the calories from fat and don’t be fooled by the percentage of fat. That number is a percentage of the total daily requirements for fat. The percentage of fat in the particular food can be much higher. To find this percentage, divide the calories from fat (279) by the total calories (320). Using this simple math, you’d find that this food is 87% fat. Remember, the American Heart Association recommends foods with less than 30% fat content.
3. Check the amount of cholesterol. Remember that cholesterol should be limited to less than 300 mg a day.
4. Check the sodium content. The 800 mg here is more than 30% of the daily allowance.
5. Check the chart. Teach your patients to compare the recommended daily amounts on this chart with the amounts in the particular food.

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LDLs transport cholesterol from the liver to the cells for deposit in peripheral tissues. An elevated LDL cholesterol level is strongly associated with the risk of heart disease. Taking the reverse route, HDLs transport cholesterol from peripheral tissues to the liver for catabolism and excretion. Increased levels of HDL cholesterol protect a person against heart disease.

Because HDL cholesterol levels are inversely related to triglyceride levels, many people with Type 2 diabetes have low levels of HDL cholesterol. This deficiency puts them at increased risk for developing atherosclerosis. As they gain better control over their blood glucose levels, their HDL cholesterol levels rise.

Patients can lower their blood lipid levels by reducing their total fat intake, losing weight, improving blood glucose levels, and changing the types of fat they consume. They should consume less than 300 mg of cholesterol per day. To help reduce cholesterol intake, patients with diabetes should eat no more than four egg yolks, the most concentrated source of cholesterol, per week.

Less than 10% of total daily calories should come from saturated fat. The acceptable amount of total fat per day, however, depends on your patient’s needs. Reducing total fat to 20% to 30% of calories reduces the risk of coronary artery disease for most people. This reduction calls for an increase in carbohydrate calories to 50% or more. While such a high-carbohydrate diet is healthy for people with Type 1 diabetes, it could increase blood glucose and triglyceride levels in insulin-resistant patients with Type 2 diabetes.

Saturated fat increases the risk of atherosclerosis by increasing levels of chylomicrons and LDLs. Most saturated fats come from dairy products, red meats, and other animal sources. Coconut oil, palm oil, and cocoa butter also contain saturated fats. Most of the fat in your patient’s diet should come from monounsaturated fats. Substituting monounsaturated fats for saturated fats may improve hypertriglyceridemia in patients with Type 2 diabetes without raising their LDL cholesterol levels. Sources of monounsaturated fats include canola, peanut, and olive oils. Your patient can also lower her cholesterol levels by substituting polyunsaturated fats-corn, sunflower, safflower, and soybean oils-for saturated fats.

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Transplantation of the whole pancreas is the only therapy that reliably achieves euglycemia. However, the procedure is undesirable for most patients with Type 1 diabetes because of the risks of rejection and infection and because it requires lifelong immunosuppressive therapy.

As an alternative, a surgeon may transplant insulin-producing islet cells in a patient who is taking immuno suppressive drugs after receiving a transplanted kidney. In islet cell transplantation, the surgeon injects islet cells from the pancreas of a cadaver into the patient’s portal vein. The cells lodge in the liver and produce insulin, functioning as if they were in the pancreas. Before injection, the cells can be treated to destroy antigen-producing cells and reduce the risk of rejection.

Most patients continue to require insulin therapy after undergoing islet cell transplantation. For many, however, glucose control improves, and insulin requirements decrease. Some patients no longer need daily insulin injections.

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Hyperglycemia is one indication of rejection, but it doesn’t develop until 90% of the islet cell mass has become compromised, at which point rejection is usually irreversible. One benefit of simultaneous transplantation is that the condition of the transplanted kidney can help the physician predict the likelihood of pancreas rejection.

Up to 30% of transplant patients develop thrombosis of the vessels that supply the pancreas. Sites of surgical anastomosis can leak. After surgery, watch for hematuria related to the kidney vessels and irritation of the duodenal portion of the pancreas graft.

Infection from opportunistic organisms may occur as a complication of immuno suppressive therapy. Fever is a sign of both acute rejection and infection, so if your postoperative patient develops a fever, perform a thorough assessment. Unrecognized rejection can mean the loss of the transplanted organ. Unrecognized infection can lead to systemic inflammatory response syndrome and death.

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Your patient should begin her exercise program with a warm-up of at least 5 minutes, gradually increasing her heart rate. She should then move on to 5 to 7 minutes of stretching to further increase her heart rate. Stretching also improves the flexibility of muscles that may be impaired by glycated muscle collagen.

Next comes the training period, which consists of 20 to 30 minutes of aerobic activity within your patient’s target heart rate. A person who hasn’t exercised in some time or who has never exercised may have to start with sessions of 5 to 10 minutes and gradually increase them to 30 minutes.

After aerobic activity, your patient should spend 10 to 15 minutes cooling down. The intensity of exercise is gradually decreased to allow her heart rate and blood pressure to slowly return to baseline. During the cooldown your patient should perform muscle-strengthening exercises for 5 to 10 minutes followed by stretching and relaxation for about 5 minutes.

Glucose tolerance declines after 24 hours with­out exercise, so your patient should exercise at least 3 days a week. Achieving continuous, improved glucose control requires even more frequent exercise. If your patient is trying to lose weight, she may have to exercise 5 or 6 days a week.

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Advise your patient to contact her physician before taking any over-the-counter drugs. She should also contact her physician before discontinuing her diabetes medication or altering its dosage. Tell your patient to always carry medical identification and a source of glucose for emergencies.

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Another method used to establish the intensity of exercise is the patient’s rating of perceived exertion. Using a scale of 0 (no exertion) to 10 (extreme exertion), she rates how hard she is working. If your patient’s perceived exertion is 3, instruct her to increase her exertion gradually until her rating reaches 5 (moderate exertion).

Show your patient how to take a pulse so that she can monitor her heart rate during exercise. Advise her that exercise shouldn’t cause shortness of breath. Explain other signs and symptoms that indicate a need to stop exercise, including light-headedness and fatigue. Review the signs and symptoms of hypoglycemia and hyperglycemia. Demonstrate how to use feelings of exertion, such as fatigue, to monitor exercise intensity. This is particularly useful for patients with autonomic neuropathy, whose heart rates may not accurately reflect the intensity of exercise.

Instruct your patient to carry medical identification and a readily available source of carbohydrate whenever they exercises.

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