Diabetes Spectrum
Volume 12 Number 2, 1999, Pages 113—117

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Clinical Decision Making

The Diabetes Nurse Practitioner: Promoting Partnerships in Care


Jane Jeffrie Seley, RN, BSN, MPH, MSN, GNP, CDE, CHES, Phyllis Furst, RN, MA, ANP-C, CDE, Terry Gray, RN, PhD, ANP-C, CDE, Donna Jornsay, RN, BSN, CPNP, CDE, and Nancy Reilly Wohl, RN, MSN, ANP-C, CDE


The treatment of diabetes is complex, involving numerous lifestyle adaptations and requiring a great deal of teaching and support. Advances in technology have contributed to the need for education and patient participation in care. Many procedures formerly performed by health care professionals, such as blood glucose monitoring, are now routinely done at home by patients.

In the past 20 years, nursing has been a major contributor to the improvement in the quality of care provided to people with diabetes, as shown in the findings of the Diabetes Control and Complications Trial.1 Working with professionals from other disciplines, nurses have helped develop and test National Standards for Diabetes Patient Education. These standards still serve as a guide to the planning, implementation, and evaluation of comprehensive, quality programs. The recognition process for meeting the National Standards for Diabetes Self-Management Education currently offered by the American Diabetes Association2 came from this initiative.

In 1986, an examination was developed through the National Certification Board for Diabetes Education (NCBDE) to certify diabetes educators.3 According to the NCBDE national office staff, there are currently 10,000 certified diabetes educators (CDEs), 50% of whom are nurses (personal communication, February 10, 1999).

Although many diabetes educators are nurses, until recently few have been nurse practitioners (NPs). The role of NPs has expanded to include the diagnosis and the medical management of both acute and chronic conditions.1

One obvious advantage of being an NP is that NPs can legally adjust the diabetes medications, order diagnostic tests, and refer patients for consultations. Diabetes educators who are not NPs are often faced with delays in treatment, lack of continuity of care, and additional expense for patients in obtaining physicians' orders. This limitation has inspired many diabetes nurse educators to consider additional training to become NPs.

Because the role of NPs in diabetes management is evolving, it is of interest to look at the components of this advanced practice role and give some real examples of how the care of people with diabetes can be enhanced by looking at several NP-managed patients. The potential contribution of NPs to primary care includes both cost containment and improved quality of care.1

Definition of a Nurse Practitioner
Nurse practitioners are registered nurses who have completed additional education and clinical training so that they may diagnose and treat many common and chronic illnesses, focusing on health promotion and disease prevention activities, including patient education and counseling.4,5

Primary Care Nurse Practice acts differ from state to state, which explains the variation in legal and prescriptive authority and reimbursement. Each year, the January issue of The Nurse Practitioner offers a state-by-state update. In general, NPs have either a certificate or a master's degree as an NP, work in collaboration with a physician, and can prescribe medications in most states.6

Responsibilities include taking histories, performing physical assessments, developing differential diagnoses, and actually managing disease, as well as using research findings to improve outcomes.7 Prescribing is particularly important in the care of people with diabetes since medications and devices are commonly recommended.3

In a survey of NPs practicing in Connecticut, it was found that most NPs see "significant numbers of patients with diabetes," often without any organized diabetes programs.8 The merging of the roles of certified diabetes nurse educator and NP promises to provide more specialized, high-quality care to patients with diabetes.

How does the NP role differ from the role of clinical nurse specialists (CNSs)? NPs perform certain medical tasks, such as carrying out physical examinations, ordering and interpreting laboratory tests, and prescribing medications. CNSs place a greater emphasis on the role of consultant and educator to patients, families, and staff. Often not directly involved in care itself, CNSs provide care providers with the necessary knowledge and skills to deliver care.9

The blending of the roles of NPs and CNSs has many advantages. They include greater likelihood of reimbursement (through NP status) and cost effectiveness, as well as greater role flexibility to include consultation, education, and research.9 Cost effectiveness includes any activities that lead to improved outcomes and a reduction in the use of expensive health care services. Whether involved in direct or indirect care, it is important for advanced practice nurses to serve as role models and continue to be leaders who creatively adapt to our rapidly changing health care delivery system.

Following are some case studies of NP-managed patients.

The Patient With Syndrome X
Nancy Reilly Wohl, RN, MSN, ANP-C, CDE

A.W. is a 56-year-old white man who presented with chest pain and newly diagnosed atrial fibrillation 6 years ago. He had a vague family history of diabetes, weighed 320 lb, had a blood glucose level of 352 mg/dl, and was diagnosed with type 2 diabetes. His primary care physician discharged him on an oral agent and scheduled follow-up visits.

The NP met A.W. 3 years later at a diabetes class, where he presented on the maximum dose of the oral agent with a hemoglobin A1c of 14.7%, weight of 290 lb, blood pressure of 146/92, increased triglyceride and low-density lipoprotein (LDL) cholesterol levels, decreased high-density lipoprotein (HDL) cholesterol, and proteinuria.

A.W. was diagnosed with Syndrome X, the term used to describe an insulin-resistant state characterized by hypertriglyceridemia, low HDL cholesterol, hyperglycemia, central obesity, and hypertension.10,11 Syndrome X patients require, at least initially, a vigilant management approach to help educate them about the many components of their condition while offering encouragement and support. NPs have the knowledge and ability to work with Syndrome X patients independently through frequent visits and telephone follow-up.

The NP, in collaboration with other members of the health care team, provided A.W. with a blood glucose meter and education and provided nutritional counseling and other information about diabetes management. Each visit included performing a focused physical examination, ordering and reviewing laboratory data, and adjusting medications. The NP was able to deliver this care independently, saving A.W. time and the institution money.

Over the next year and a half, A.W. was able to dramatically improve his health status. The NP placed him on insulin therapy and quickly changed to BIDS therapy (bedtime insulin, daytime sulfonylurea). An angiotensin-converting enzyme inhibitor helped manage his hypertension as well as his renal insufficiency. Unfortunately, A.W. was not a candidate for metformin because of a history of alcohol use.

As his blood glucose levels improved, so did his lipid profile. Weekly visits coordinated by the NP with other health care providers (e.g., psychiatrist, podiatrist, dietitian, ophthalmologist) along with frequent telephone triage calls by the NP to review blood glucose values and make adjustments in the treatment regimen substantially improved his status.

A.W. has recently married, lost 25 lb, has a normal lipid profile, and has controlled hypertension, reduced proteinuria, and a hemoglobin A1c of 8.0%. He is on 5 mg of glipizide in the morning and 10 U of lente insulin at bedtime. He comes to regularly scheduled appointments with the NP and no longer requires telephone triage but feels free to call when assistance is needed.

The NP was able to provide the medical management, education, and coordination of the interdisciplinary services that were needed to achieve success in the complex care required for this Syndrome X patient.

The Patient With a Nonhealing Foot Ulcer
Terry Gray, RN, PhD, ANP-C, CDE

B.F. is a 63-year-old black man with a 20-year history of type 2 diabetes, hypertension, arteriosclerotic heart disease (ASHD), peripheral vascular disease (PVD), and peripheral neuropathy. Although he had noticed a yellowish drainage on his sock and an odor from his shoes approximately 1 month before his visit, he delayed seeking treatment.

B.F. had stopped seeking medical care 3 years ago when he was advised to begin insulin therapy but refused. Within a short time after starting insulin, B.F.'s father suffered a lower-extremity amputation and died, and B.F. feared the same fate. Now he has just "found a big hole" in the bottom of his foot and knew he needed help.

The NP examined B.F. and diagnosed acute cellulitis and a chronic infected ulcer. Pressure sensation was measured using the Semmes-Weinstein monofilament. B.F. was placed in risk category 3 due to the presence of the ulcer and inability to perceive filament sensation.12

It was decided to treat B.F. as an outpatient with elevation of the extremity, bed rest, and complete nonweight bearing because any pressure from continued use of the injured area would spread the infection into adjacent tissues.

An X ray was ordered to rule out osteomyelitis. Amoxicillin, a broad spectrum antibiotic covering both aerobic and anaerobic organisms, was chosen because most chronic infected ulcers are polymicrobial in nature.13 The NP reviewed blood glucose monitoring technique and asked B.F. to test at home four times a day and to call in the results weekly.

The NP closely followed B.F., and the ulcer healed within 2 months. Follow-up included discussions about blood glucose values and the importance of adherence to recommendations regarding diet, activity, foot care, prevention and treatment of hypoglycemia and hyperglycemia, and stress management. B.F. was referred for extra-depth, molded shoes in an effort to prevent a recurrence of the ulceration.14,15

Complicating factors in this case included the presence of significant ASHD, dyslipidemia, PVD, and an insensate foot. The radiological examination demonstrated soft tissue swelling but no evidence of osteomyelitis. After a Doppler study revealed significant lack of blood flow to the left lower extremity (LLE), B.F. was referred to a vascular surgeon for evaluation and treatment. He underwent a successful femoral-popliteal bypass graft of the LLE.

The dyslipidemia was addressed using dietary modifications, exercise, and a fibric acid derivative, gemfibrozil.16 After 6 months, the lipid profile improved.

B.F.'s inability to perceive pain and fear of insulin therapy precluded his seeking medical treatment in a timely manner. Once under the care of the NP, B.F. discussed his fears and learned the benefits of glycemic control.

He was immediately enrolled in the hospital-based diabetes self-management training program, where the NP is one of the instructors. He completed the course and became more attentive to his diet, blood glucose monitoring, and an "arm-chair" exercise program, and lost 14 lb. These activities were instrumental in lowering his HbA1c from 14.5 to 8.9%.

B.F. now understands the danger of an insensate foot and is meticulous in his daily foot care, making sure to include a thorough foot inspection every morning and evening. The close relationship he developed with the NP helped support him through this complex treatment plan. The NP offered not only medical management, but a great deal of education and encouragement, which facilitated B.F.'s adjustment to lifestyle changes that were necessary for him to achieve success.

Initiating Insulin Pump Therapy
Phyllis Furst, RN, MA, ANP-C, CDE

C.O., a 26-year-old white man with type 1 diabetes for 8 years, was referred to the NP for counseling and initiation of insulin pump therapy. He frequently had to work late hours and found that he had difficulty maintaining good glycemic control on multiple daily injections due to his demanding and unpredictable schedule.

The NP discussed the pros and cons of insulin pump therapy.17 C.O. was enthusiastic about the increased flexibility the pump would provide. Issues such as exercise and dating were explored. Both available insulin pumps were demonstrated, as well as the various choices of infusion sets.

After obtaining insurance coverage for the pump, C.O. was ready to begin the intensive, 8-hour pump training program, consisting of six individual outpatient visits with the NP. During the training, the NP reviewed skills such as blood glucose monitoring, hypoglycemia management, ketoacidosis prevention, and sick-day management. The nutritionist reviewed the meal plan and instructed C.O. in carbohydrate counting.

Next, the NP began to demonstrate pump programming and function applications, insulin supplementation for high blood glucose levels, the protocol for clogged infusion sets, and pump alarms and discussed when to seek medical help.17 Based on his total daily dose of insulin before initiation of insulin pump therapy, the NP calculated C.O.'s starting basal insulin rate of 0.6 U/hour as well as his initial meal bolus amounts.

C.O. left that visit wearing the pump with normal saline and mimicked actual pump usage for the next 10 days. He continued his previous multiple daily injection program during this time.

For the fourth visit, C.O. came to the office fasting, with plans to have breakfast after the insulin was placed in the pump for the first time. His physician was called to review the planned insulin rates. Because C.O. planned to return to the referring physician for his diabetes management once stable on the pump, it was important to involve his physician in the dosage adjustments.

C.O. was asked to review blood glucose levels and insulin rates by phone with the NP or the physician for the next 57 days. A return visit was scheduled with the NP 2 days later to troubleshoot pump questions, as well as to review blood glucose levels and make basal and bolus rate adjustments as needed. C.O. again demonstrated his skill in preparing and inserting a new pump syringe and infusion set.

C.O. continued to call the NP once daily for the next 5 days and was able to achieve his target blood glucose levels in 10 days. Although this seems labor-intensive, it offers an important safety and support net for outpatient insulin pump initiation. C.O. scheduled an appointment for a follow-up visit with the NP 2 weeks after the initial insulin-start visit.

A change to insulin pump therapy is a major therapeutic and lifestyle adjustment for people with diabetes. The NP's careful attention to the physiological, educational, psychological, emotional, and comfort aspects of insulin pump therapy eased the transition.

Managing the Pregnant Patient With Diabetes
Donna Jornsay, RN, BSN, CPNP, CDE

T.V., a 36-year-old woman at 18 weeks gestation, was referred by her private obstetrician for diabetes education and counseling with the diagnosis of gestational diabetes. Her medical history was insignificant except for a pre-pregnancy weight of 350 lb. Her height is 5'9".

The patient was screened earlier than usual because of risk factors for diabetes, including her weight and the presence of glycosuria. The 3-hour glucose tolerance test (GTT) results were as follows:

Fasting Abnormal Values
152 mg/dl >95 mg/dl
1-hour
390 mg/dl >180 mg/dl
2-hours
393 mg/dl >155 mg/dl
3-hours
376 mg/dl >140 mg/dl

Normal values have recently changed and are based on the criteria adopted by Carpenter and Coustan.18

Given the abnormality of the GTT and her symptoms of diabetes, T.V. was informed that her diabetes was most likely type 2 rather than gestational diabetes. The NP began treatment by teaching T.V. about the maternal and fetal risks of diabetes during pregnancy, including the increased risk (up to 25%) of congenital malformations. T.V. was informed that although she did have an increased risk for a congenital malformation, an ultrasound and fetal echocardiogram performed at 1822 weeks gestation would provide an accurate diagnosis of the fetus's condition. The NP outlined the advantages of maintaining excellent glycemic control for the remainder of the pregnancy, including decreasing the fetal risks of macrosomia and stillbirth and the neonatal risks of hypoglycemia, hyperbilirubinemia, polycythemia, and hypocalcemia.18,19

The NP discussed the probability of previously undiagnosed type 2 and outlined the necessary treatment. This included dietary management, fasting and 1-hour postprandial blood glucose monitoring, urine ketone monitoring, multiple daily insulin injections (NPH and regular before breakfast, regular before dinner, and NPH at bedtime), and outpatient fetal monitoring. The NP instructed T.V. in blood glucose monitoring, urine ketone testing, insulin self-administration, and exercise guidelines.

A registered dietitian gave her a 2,400-calorie American Diabetes Association (ADA) meal plan as calculated based on her weight and caloric needs for pregnancy. The meal plan included three main meals and three snacks per day.

All of this information was presented slowly, allowing time for questions and expressions of feelings.

As the NP was teaching T.V. blood glucose monitoring, her blood glucose level was 237 mg/dl 2 hours after breakfast. After discussing the situation with T.V., the NP decided to admit her to the inpatient high-risk obstetric unit to expedite her education and glycemic control. Her HbA1c at this time was 11.7% (normal 4.46.4.%), thereby giving the fetus a 22% risk of a congenital malformation.19

The NP provided medical management and coordinated T.V.'s care, including ordering a comprehensive ultrasound as soon as possible (ideally done at 1820 weeks gestation) and a fetal echocardiogram at 2022 weeks to rule out any malformations.20 The NP reviewed the results of these tests and discussed them with T.V. Fortunately, both of these exams were within normal limits.

T.V. needed much support and reassurance as she began to grasp the concept that her diabetes would most likely not go away at the end of her pregnancy. Fortunately, her dilated eye exam, 24-hour urine, and EKG were all within normal limits, thereby indicating that she had not developed any chronic complications of diabetes.

Insulin treatment was initiated at 0.8 U/kg current weight, which is recommended for 18 weeks gestation. Her current weight was 165 kg. Her initial insulin regimen was 56 U NPH/28 U regular 30 minutes before breakfast; 22 U regular 30 minutes before dinner; and 22 U NPH at bedtime. Based on T.V.'s obesity, the NP steadily increased these doses up to approximately 300 U of insulin by the time of delivery.

The first week after discharge, the NP maintained daily phone contact with the patient to review her blood glucose results and to adjust her insulin doses and meal plan as needed.21 From 19 weeks gestation onward, the patient was able to be managed as an outpatient with weekly phone contact and biweekly visits to the NP in addition to her regular obstetric visits. The insulin doses increased as the pregnancy progressed, and she was able to maintain her blood glucose values within the expected range of 60120 mg/dl.

The NP initiated daily fetal movement recording at 26 weeks. Based on her initial poor glycemic control, twice weekly nonstress testing was begun at 32 weeks, and serial ultrasounds were done to assess fetal growth. All her fetal surveillance testing was within normal limits.

T.V.'s care was specialized and labor-intensive. The NP was able to provide the continuity and attention that T.V. needed to see her through this high-risk pregnancy.

T.V. had a vaginal delivery of a 7 lb, 3 oz baby at 37 weeks gestation. Her baby girl was in the neonatal intensive care unit for several days with hyperbilirubinemia and difficulty feeding, but did well.

Two years postpartum, T.V. has lost approximately 50 lb. and is continuing to lose weight. She has type 2 diabetes for which she is currently being treated with three injections per day of insulin after failing on oral agents. Since this NP only treats diabetes in pregnancy, she referred T.V. to the NP in adult endocrinology to control her glucose values so that she can avoid long-term complications of diabetes and be able to share a long and healthy life with her husband and children.

Conclusion
Jane Jeffrie Seley, RN, BSN, MPH, MSN, GNP, CDE, CHES

Managing patients with diabetes effectively requires a great deal of time, effort, and patience. As discussed in the cases outlined above, diabetes NPs are able to deliver quality, cost-effective care by applying all of the combined skills and knowledge from their training as nurses, NPs, and diabetes educators.

Studies looking at the effectiveness of NPs in primary care reveal not only competence but equivalent or slightly improved patient outcomes, most likely because the NPs spend more time talking with patients and individualizing treatment regimens.22 The trend for more diabetes nurse educators to become diabetes NPs can only lead to better care for people with diabetes. In the future, diabetes NPs could be utilized in primary care settings where there is a high volume of patients with diabetes.

As a gerontological NP presently consulting in a busy general medicine practice (Beth Israel Medical Center's General Medical Associates [GMA]), I am able to provide a higher level of care to my patients with diabetes because I also bring to them 20 years of experience as a diabetes nurse educator. My colleagues value my ability to support my patients through the complex management plan. I am thought of as an expert in diabetes management as well as in successfully helping patients adhere to the complex medical regimens prescribed.

Collaboration with the physicians and other NPs in the practice works both ways and benefits both providers and patients. More diabetes patients are thereby able to receive a higher level of care at a lower cost in a general medical practice. Patients continue to be referred to endocrinologists when blood glucose levels are not well controlled within a reasonable period of time.

Many NPs like myself are already providing primary care to populations known to be at higher risk for diabetes, e.g., minorities and the elderly. However, more research is needed to evaluate the effectiveness of diabetes NPs in collaborative practice in primary care and to establish if they are truly delivering quality, cost-effective care according to the standards set by the American Diabetes Association.1

GMA joined its affiliate St. Luke's-Roosevelt in instituting the Diabetes Initiative Plan to improve care delivery to patients with diabetes. GMA physicians and NPs worked together to develop a diabetes checklist, which is included on the medical record of all GMA patients with diabetes. The checklist reminds providers when to perform appropriate testing and evaluations such as HbA1c levels, foot examinations, and podiatric referral, according to ADA standards of medical care for patients with diabetes. This program has been very successful to date.

The next step will be to improve the knowledge of the current treatment of diabetes among GMA providers. Professional education that increases awareness of the importance of diabetes management is a valuable tool in reducing and preventing the complications of diabetes.1 Diabetes NPs can serve as role models and educators, offering professional education in diabetes care and management to their colleagues in primary care. This is a perfect blend of the CNS and NP roles.


References
1Fain JA, D'Eramo-Melkus G: Nurse practitioner practice patterns based on standards of medical care for patients with diabetes. Diabetes Care 17:879-81, 1994.

2Task Force to Revise the National Standards: National standards for diabetes self-management education programs. Diabetes Care 18:100-16, 1995.

3Nettles AT, Kreitzer MJ: Trends in advanced nursing practice and implications for care of diabetes patients. Diabetes Spectrum 7:344-49, 1994.

4American College of Nurse Practitioners: Fact Sheet: What Is a Nurse Practitioner? Washington, D.C., 1996.

5American Nurses Association: Nursing Facts: Advanced Practice Nursing: A New Age in Health Care. Washington, D.C., 1992.

6Pearson LJ: Annual update of how each nurse stands on legislative issues affecting advanced practice nursing: a survey of legal authority, reimbursement status, and prescriptive authority. Nurs Pract 22:18-86, 1997.

7Arcangelo V, Fitzgerald M, Carroll D, Plumb JD: Collaborative care between nurse practitioners and primary care physicians. Primary Care 23:103-13, 1996.

8D'Eramo-Melkus G, Fain JA: Diabetes care concentration: a program of study for advanced practice nurses. Clin Nurs Spec 9:313-16, 1995.

9Mezey MD, McGivern DO: Nurses, Nurse Practitioners: Evolution to Advanced Practice. New York, Springer Publishing Company, 1993.

10Bloomgarden ZT: The lipid triad and cardiovascular disease. Pract Diabetol 12:6-8, 1993.

11Flack JM, Sowers JR: Epidemiologic and clinical aspects of insulin resistance and hyperinsulinemia. Am J Med Suppl 1A:S11-18, 1991.

12Albert SG, Plummer ES: Office management of foot problems. Pract Diabetol 13:2-7, 1994.

13American Diabetes Association: Clinical Practice Recommendations. Diabetes Care 20 (Suppl 1): S5-70, 1997.

14Helfand AE: Therapeutic footware. Pract Diabetol 15:4-9, 1996.

15Reiber GE: Diabetic foot care: financial implications and practice guidelines. Diabetes Care 15 (Suppl. 1): 29-31, 1992.

16Bloomgarden ZT: Assessing lipid disorders in diabetes. Pract Diabetol 13:10-11, 1994.

17Strowig SM: Initiation and management of insulin pump therapy. Diabetes Educ 19:50-59, 1993.

18Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Workshop Conference on Gestational Diabetes Mellitus. Diabetes 21 (Suppl 2):B161-67, 1998.

19Nagusky D, Bell-Hart M: Role of the nurse practitioner in diabetes and pregnancy management. Nurs Pract Forum 2:196-98, 1991.

20Jornsay DL, Smith-Levitin M, Petrikovsky B: Diabetes in pregnancy: how to manage? Part I: Screening and counselling. Neonatal Intensive Care 10:45-50, 1997.

21Jornsay DL: Monitoring. In Medical Management of Pregnancy Complicated by Diabetes. Jovanovic-Peterson L, ed. Alexandria Va., American Diabetes Association, 1995, p. 29-38.

22Funnell MM: Role of nurses in the implementation of intensified management. Diabetes Revs 2:326-28, 1994.


Jane Jeffrie Seley, RN, BSN, MPH, MSN, GNP, CDE, CHES, is a diabetes nurse practitioner in the Diabetes Management Program at Beth Israel Healthcare System in Manhattan, N.Y. Phyllis Furst, RN, MA, ANP-C, CDE, is an adult diabetes nurse practitioner and program coordinator at North Shore University Hospital in Manhasset, N.Y. Terry Gray, RN, PhD, ANP-C, CDE, is an adult diabetes nurse practitioner and program coordinator for the diabetes program at North Shore-Long Island Jewish Health System in New Hyde Park, N.Y. Donna Jornsay, RN, BSN, CPNP, CDE, is the clinical coordinator for the diabetes and pregnancy program at North Shore University Hospital in Manhasset, N.Y. Nancy Reilly Wohl, RN, MSN, ANP-C, CDE, is a diabetes nurse practitioner at the Department of Veterans Affairs New York Harbor Health Care System in Manhattan, N.Y.


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