cardiovascular disease, type 2 diabetes, cancer and · pdf filecardiovascular disease, type 2...

Tanzania Diabetes Association World Diabetes Foundation

Desemba 2013

Ministry of Health and Social Welfare

Chronic Non Communicable Diseases

Cardiovascular Disease,

Type 2 Diabetes, Cancer

and COPD in adults

United Republic of Tanzania

Case Management Desk Guide

NCD Desk Guide.indd 1 1/24/14 5:18 PM

United Republic of Tanzania

Ministry of Health and Social Welfare

Chronic Non Communicable Diseases

Cardiovascular Disease, Type 2 Diabetes, Cancer, and COPD in adults

Case Management Desk Guide

December 2013

Tanzania Diabetes Association World Diabetes Foundation


Contents

Introduction .............................................................................................................................. 1The Chronic Care Model .......................................................................................................... 2FOR ALL CONSULTATIONS .................................................................................................. 3WEIGHT LOSS ........................................................................................................................ 5SUMMARY .............................................................................................................................. 4UNHEALTHY DIET .................................................................................................................. 6PHYSICAL INACTIVITY .......................................................................................................... 7TOBACCO ............................................................................................................................... 8ALCOHOL ................................................................................................................................ 9OVERWEIGHT AND OBESITY ............................................................................................. 10COPD & ASTHMA – SYMPTOMS ........................................................................................ 11COPD & ASTHMA – DIAGNOSIS ......................................................................................... 12ASTHMA - TREATMENT AND FOLLOW UP 1 ..................................................................... 13ASTHMA - TREATMENT AND FOLLOW UP 2 ..................................................................... 14COPD - TREATMENT AND FOLLOW UP ............................................................................ 15CARDIOVASCULAR DISEASE (CVD) .................................................................................. 16HYPERTENSION - DIAGNOSIS AND TREATMENT ............................................................ 17HYPERTENSION – MEDICATION ........................................................................................ 18HYPERTENSION - FOLLOW-UP .......................................................................................... 19HEART FAILURE .................................................................................................................. 20STROKE ................................................................................................................................ 21LIPID CONTROL ................................................................................................................... 21DIABETES - DIAGNOSIS 1 ................................................................................................... 22DIABETES - DIAGNOSIS 2 ................................................................................................... 23DIABETES – TREATMENT AND FOLLOW UP 1 ................................................................. 24DIABETES - FQLLOW UP AND REFERRAL ........................................................................ 25DIABETES - TREATMENT AND FOLLOW UP 3 .................................................................. 26DIABETES - INSULIN PRESCRIPTION ................................................................................ 27DIABETES - DIABETIC FOOT .............................................................................................. 28DIABETES IN CHILDHOOD .................................................................................................. 28SEVERELY ILL PATIENTS ................................................................................................... 29SEVERELY ILL PATIENTS – THE UNCONCIOUS .............................................................. 30TREATMENT SUPPORTER ................................................................................................. 31Medicine: Contra-Indications and Major Side Effects ............................................................ 32Useful Resources .................................................................................................................. 33Acronyms ............................................................................................................................... 34


Ministry of Health & Social Welfare and Tanzania Diabetic Association 1

Introduction The Goals and Objective of this desk guide is to screen; early detect and manage initially patients with cancers, chronic respiratory disease and linked asymptomatic conditions of type 2 diabetes mellitus, hypertension, obesity and hyperlipidaemia, alcoholism and smokers in a local health unit in primary care or the district hospital OPD. It is to educate patients about lifestyle measures and specific treatments so that they can take responsibility for their own care. It is a concise “quick reference” guide for doctors, clinical officers, nurses, nurse assistants and counsellors providing routine care and health education. There is provision for monitoring and evaluation of management to prevent complications and untimely death. It clearly indicates when referral to district hospital and assessment by a more senior clinician is appropriate. However once stable, they may then be referred back with a care plan for follow-up at the nearest health unit.

They are based on WHO and International Diabetes Federation (IDF) guidelines. In particular refer to IDF “Type 2 Diabetes Clinical Practice Guidelines for SSA”, WHO “Package of Essential Non Communicable Disease Interventions (PEN) for Primary Health Care, WHO hypertension Guidelines and Tanzania National Treatment Guidelines.

They have been adapted to Tanzania by an expert group, for the local health service context, the availability of trained staff, drugs, basic equipment, tests (and units) and to conform to the Tanzania National Treatment Guidelines, using a generic version authored by Dr Kirti Kain, Senior Lecturer in Community Diabetes, LIGHT and Professor John Walley, Professor of International Public Health, Nuffield/ LIHS, University of Leeds UK. The Tanzania adaptation was by a working group of the Ministry of Health & Tanzania Diabetes Association. The flowchart format is thanks to the NCD Unit of the Ministry of Health, Zanzibar.

These interim guidelines will be revised based on early implementation experience. Please send comments to: Tanzania Diabetic Association, P.O. Box 65201, Dar es Salaam; email: [email protected].

Ministry of Health & Social Welfare and Tanzania Diabetes Association



The Chronic Care Model

Each consultation for a patient with a chronic condition should follow the model as below.

The model has 4 parts:

1. Consultation: this involves assessing and testing the patient, referring them where necessary and completing a register and treatment card

2. Lifestyle advice: this involves disease specific education, lifestyle advice, support for medication

adherence and setting up a treatment contract (on the first consultation only) 3. Follow-up: this involves assessing the patient at a follow-up appointment and addressing their concerns

and questions 4. Counsel: send to a health educator/ counselor if available, or counsel yourself: at each of the initial

consultations, then less frequently depending on progress.

It is recommended that you complete each of the 4 parts as outlined. The first stage takes longer in the initial consultations.




FOR ALL CONSULTATIONS

Take Medical History Enquire about the current: Complaints Symptoms Duration Frequency Intensity Be sure to include a past medical history. Ask about other chronic disease(s)

Examine the Patient

Use thermometer, stethoscope, blood pressure and blood glucose machine where relevant

Inform Patient About Your Tentative Diagnosis

Severely III Patients

If patient looks severely ill and/or shows the features below refer urgent to hospital.

Rapid pulse >125/minute

Breathing >30/minute

Low BP <90/60 mmHg

Very high BP >200/120 mmHg

Fever>39°C

Immediately refer unconscious patients.

If lips are "blue"

If confused

Severe abdominal pain/vomiting

Chest pain radiating to left arm or shoulder

Shortness of breath

29 for what to do while arranging transfer and first aid

For All Not Acutely ill Patients

Offer to assess Cardiovascular Disease risk 16




SUMMARY Risk Factors for Chronic Non-Communicable Diseases

Unhealthy

Diet Tobacco Alcohol Raised Blood

Pressure Overweight Physical

Inactivity

Symptoms for Chronic Diseases:

Symptoms often present > 2 weeks Recurring symptoms No acute onset Gradual / slow onset Non Communicable Diseases can be 'silent' or symptoms can be vague/unspecific. Consider the corresponding disease if the following symptoms are present:

� Chest pain (with exercise/when cold) � Awareness of heartbeat � Prominent neck vessels � Abdominal swelling � Breathlessness (if < 2 weeks, in the

presence of cough, consider pneumonia, >2 weeks do TB sputum smears)

� Ankle swelling in both legs � Pain in the back of the legs (calf

muscles) on walking � Slurred speech, one-sided/deviation

of the mouth

Cardiovascular Disease

� Chronic cough (more than 2 weeks) +/- sputum production

� Gradually worsening breathlessness

� Worsening with physical exercise

� Recurrent chest infections � Have been smoking or exposed

to biomass fuels for years

Chronic Lung

Disease (COPD)

� Intermittent shortness of breath

Wheezes � Cough, often at night/mornings � Symptoms since childhood

Asthma

� Unexplained weight loss (counsel

and test for HIV, TB and Diabetes) � Worsening fatigue (tiredness) � Persistent low-grade fever � Unexplained pain � Lumps of more than 3 weeks (neck,

armpit, abdomen, skin or breast) � Change in bowel habits � Excessive vaginal discharge � Abnormal bleeding (e.g. in stool,

urine, sputum, nose bleed, or in women post-coital, outside regular cycles, or after the menopause)

� Difficulty in swallowing � Persistent cough/hoarse voice > 3

weeks � Skin changes/ a non healing sore � Change in urine frequency, flow,

hesitancy � Change in breasts: appearance, size,

shape, feel, nipple discharge

Cancer

� Lethargy � Thirst � Frequent micturation � Recurrent infections (e.g. Urine,

skin, thrush) � Sensory disturbances � Blurred vision � Un-healing wound � Foot ulcer

Diabetes

Remember not only to manage patients' symptoms but also chronic disease risk factors through health education and practical advices (see coming pages)




WEIGHT LOSS

Weight Loss Requiring Urgent Attention

Check if the client has intentionally lost weight, compare current weight with previous records and ask if their clothes still fit. Unintentional weight loss of >5% of body weight is significant and must be investigated

First Check for TB, HIV, and Diabetes

Exclude TB Start workup for TB At the same time, test for HIV and Diabetes. 22 Consider other causes below.

Test for HIV If status is unknown, test for HIV The HIV client with weight loss >10% and diarrhoea or fever >1 month needs ART. Refer to CTC

Check for Diabetes Check random finger-prick blood glucose To interpret result see 22

Ask About Symptoms of Common Cancers Abnormal vaginal discharge/ bleeding

Breast lumps or nipple discharge

Urinary symptoms in men

Change in bowel habit

cough > 2 weeks, blood-stained sputum, long smoking history

Consider cervical cancer. Do a speculum examination

Consider breast cancer. Examine breasts/ axillae for lumps

Consider prostate cancer. Hard and nodular prostate on rectal examination

Consider bowel cancer. Mass on abdominal or rectal examination. Occult blood positive.

Consider lung cancer. Do a chest X-Ray.

If Food Intake Inadequate, Look for a Cause

Nausea and/or vomiting Loss of appetite

Ask 'Are you stressed?'

Improper Diet

Sore mouth or difficulty swallowing

Referral for Investigation 29

Eat small frequent meals. Drink high energy drinks (milk, sweetened fruit juice). Increase energy value of food by adding sugar, milk powder, peanut butter or oil.

If yes, counsel patient or refer

Refer to nutrition scheme

Oral/oesophageal thrush likely Treat with medication, investigate cause

Check thyroid (TSH) if none of the above and client has: pulse >80, tremor, irritability, dislike of hot weather or thyroid enlargement

Refer within 1 month for further investigation the client with persistent documented weight loss and no obvious cause




UNHEALTHY DIET Unhealthy Diet Balanced Diet Diabetic Diet

Excessive carbohydrates

Excessive sugar

Excessive fats & oils

Excessive animal fats

Excessive salt

Excessive red meat

Avoid sugar and sodas

No need for special diabetes food, nutritional supplements products or artificial sweeteners

Be careful with alcohol which can make you very ill because it lowers blood sugar levels (if on insulin or sulphonylurea tablets).

Portion Size Matters Carbohydrates Proteins Vegetables Fats Fruit

Equivalent to two fists

Size of palm and thickness of little finger

Enough to fill both hands

Size of the tip of your thumb

Equivalent of a fist

Content of Diet, Specific Advices

Eat breakfast, lunch and evening meal - evenly distributed throughout the day.

Eat fish and chicken rather than red meat, remove visible fat.

Drink enough safe/clean water, approximately 2 litres per day Drink little or no alcohol (<2 units/day for men, < 1 unit/day for women)

Use unrefined food/cereals, (whole grain)

Reduce fats - especially animal fat.

Replace coconut milk or palm oil with olive, soya, or sunflower oil.

Use < 2 tablespoon of oil per person per day for cooking.

Add only a little salt when cooking, but not at the table (maximum 5 g/day per person = 1 teaspoonful/day).

Eat as a family - healthy eating is good for all family members!

Avoid ready-made (processed) or street food, as is unhealthy with a lot of fat and salt, home cooked is better

Avoid fried food: grill, boil or steam food for shortest necessary time.

Eat fresh fruits and vegetables every day, at least 6 servings in total. See below for examples of servings Avocado Mchicha Papaya Watermelon Banana Small

Mango Balungi (grapefruit)

Orange

piece 1 cup piece 1 large 1 piece 1 piece piece 1 piece




PHYSICAL INACTIVITY

The Need for Physical Activity Cut down sitting for more than 30 minutes at a time

Carry out activity which you enjoy and which you can do every day for at least half an hour. Examples of daily activity are:

Fast walks Football or basketball Dance Swim Jog or run Field work Use jumping rope

The required intensity of the activity is equivalent to walking 100 steps per minute. This should be double regular speed and should be hard enough to make you out of breath or sweat

Suggestions

Suggest types of physical activity that is suitable for the specific patient considering age, gender, fitness and opportunities. Examples:

� Joining an exercise and fitness group (obama group, kitambi noma)

� Designate a walking route to walk with a friend every day

� Types of physical activity suitable for the specific patient

� Make an exercise schedule

� Exercise with spouse, friends, or kids

Leisure Activities & Strength Activities

2-3 Times per week

Golf Gardening Stretching

Lifting weights Bowling

Aerobic Exercise & Recreational

3-5 Times per week

Accumulate a total of 30 minute

Cycling Swimming Football Tennis

Basketball Dancing Hiking

Rowing

Take Extra Steps

Everyday

Use stairs instead of a lift Mow the lawn

Walk the longest route Parking further away from home

Note Take and record blood pressure before doing exercise




TOBACCO

Tobacco Usage Smoking Chewing Sniffing

� Ask all Patients:"Do you smoke/sniff/chew?" � Recommend to stop using tobacco � Do not be judgemental - be supportive!

Advise the Patient

If you continue to use tobacco, you are more likely to have cancer, impotence (men), strokes, kidney disease, heart attacks and peripheral vascular disease.

Smoking worsens asthmas, it is also a cause of bronchitis and COPD

Giving up tobacco is the most important thing to do to protect heart and health.

If it is difficult to stop tobacco it is best to ask non-using family and friends to help you.

Avoid the company of smokers, and say a big NO if people offer you a cigarette.

Passive smoking is bad for your health, avoid being a second-hand smoker.

� Ask: "Have you thought of stopping?" � If the patient is motivated: Assist them in preparing a quitting plan

Quitting plan

The Patient Should: Set a quit date Inform family and friends Ask for their support Remove cigarettes/tobacco Remove objects/articles that prompt you to smoke Find an alternative to smoking (chewing gum, chewing nuts, etc)




ALCOHOL � It is recommended to abstain from alcohol � People should not be advised to start taking alcohol for health reasons � Men who take more than 2 units per day and women who take more than 1 unit per day should be

advised to reduce their intake. � Alcohol should not be consumed everyday

Measuring Alcohol One unit of alcoholic drink is defined as the equivalence of 10-12 g alcohol (One unit is one of the following: one small bottle of beer/lager (5% alcohol); one small glass of wine (10% alcohol), one tot of spirits (40% alcohol)

Examples of Units of Alcohol Kiroba Glass Wine Shot Alcohol Export Beer Local Beer Gongo

3 Units 1 Unit 1 Unit 1 Unit 2 Units 4 Units

Facts Long term intake of >3 units of alcohol a day is associated with adverse side effects such as hypertension, stroke etc Advise patients not to use alcohol when additional risks are present, such as:

Driving or operating machinery Pregnant or breast feeding Taking medications that interact with alcohol Having medical conditions made worse by alcohol Having difficulties in controlling amount or frequency of drinking.

If having a drinking problem: 1) Explore if the patient is motivated to stop drinking 2) suggest patient to be referred to: 3) Follow up weekly

Substance Abuse Program, Alcoholic Anonymous Counselor




OVERWEIGHT AND OBESITY

Measurement Overweight Obesity

Men Women Men Women Body Mass Index (BMI) >25 kg/m2 >25 kg/m2 >30 kg/m2 >30 kg/m2 Waist Circumference (WC) >102 cm >88 cm Waist-Hip Ratio (WHR) >0.9 >0.82

BMI WC WHR

BMI = Weight

Height x Height WC = Waist in cm WHR = Waist

Hip

Help patient to set a (weight) goal and encourage changes Inform the patient that in the beginning weight can be lost quickly, but to keep loosing and maintaining a healthy weight can be a challenge Increase daily physical activity 7 Encourage the whole family to start more healthy eating habits: Eat plenty of vegetables. Cut out all sugary drinks Reduce meal sizes Follow a balanced diet and other advises 6

Body Mass Index (BMI)

Weight in Kilograms Healthy Overweight Obese 45 50 54 58 63 68 73 77 82 86 91 95 100 104 109 113

Hei

ght i

n M

eter

s

1.46 22 25 26 29 31 34 36 38 40 43 45 47 49 52 54 56 1.47 22 24 26 28 30 33 35 37 39 41 43 45 48 50 52 54 1.49 21 23 25 27 29 31 34 36 38 40 42 44 46 48 50 52 1.50 20 22 24 26 28 30 32 34 36 38 40 42 44 45 49 51 1.52 20 22 23 25 27 29 31 33 35 37 39 41 43 45 47 49 1.55 19 21 23 25 26 28 30 32 34 36 38 40 42 44 45 47 1.57 18 20 22 24 26 27 29 31 33 35 37 38 40 42 44 46 1.60 18 20 21 23 25 27 28 30 32 34 35 37 39 41 43 44 1.63 19 21 22 24 26 28 29 31 33 34 36 38 40 41 43 1.65 18 20 22 23 25 27 28 30 32 33 35 37 38 40 42 1.67 18 19 21 23 24 26 27 29 31 32 34 36 37 39 40 1.70 19 20 22 24 25 27 28 30 31 33 35 36 38 39 1.73 18 20 21 23 24 26 27 29 30 32 34 35 37 38 1.75 18 19 21 22 24 25 27 28 30 31 33 34 35 37 1.78 19 20 22 23 24 26 27 29 30 32 33 35 36 1.80 18 20 21 22 24 25 27 28 29 31 32 34 35 1.83 16 18 19 20 22 23 24 26 27 28 30 31 33 34 1.85 16 19 20 21 22 24 25 26 28 29 30 32 33



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to S

albu

tam

ol

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

13

AST

HM

A -

TREA

TMEN

T A

ND

FO

LLO

W U

P 1

A

dvis

e th

e Pa

tient

:

How

to li

ve w

ith A

sthm

a E

xpla

in w

hat a

sthm

a is

, wha

t can

trig

ger

an a

ttack

and

ho

w to

live

with

ast

hma

Ens

ure

they

und

erst

and

the

need

for t

reat

men

t

�

Avo

id s

mok

ing,

cig

aret

te s

mok

e an

d ot

her t

rigge

r fa

ctor

s fo

r ast

hma,

if k

now

n �

Red

uce

dust

as

muc

h as

pos

sibl

e by

usi

ng d

amp

clot

hs to

cle

an fu

rnitu

re, s

prin

klin

g th

e flo

or w

ith

wat

er b

efor

e sw

eepi

ng, c

lean

ing

blad

es o

f fan

s re

gula

rly a

nd m

inim

izin

g so

ft to

ys in

the

slee

ping

ar

ea.

� U

nder

stan

ds th

e be

nefit

from

usi

ng in

hale

rs ra

ther

th

an ta

blet

s, a

nd w

hy a

ddin

g a

spac

er is

hel

pful

. �

Kno

ws

wha

t to

do if

ast

hma

dete

riora

tes

�

It m

ay h

elp

to e

limin

ate

cock

roac

hes

from

the

hous

e (w

hen

the

patie

nt is

aw

ay) a

nd s

hake

and

exp

ose

mat

tress

es, p

illow

s, b

lank

ets,

etc

. to

sunl

ight

. �

Reg

ardi

ng tr

eatm

ent,

ensu

re th

at

the

patie

nt o

r par

ent i

s aw

are

that

in

hale

d st

eroi

ds ta

ke s

ever

al d

ays

or e

ven

wee

ks to

be

fully

effe

ctiv

e �

Avo

id d

usty

and

sm

oke-

fille

d ro

oms

See

that

the

patie

nt is

usi

ng

spra

y/in

hale

r co

rrec

tly

Bet

a - a

goni

st fo

r qui

ck s

ympt

om re

lief

Ste

roid

for r

educ

ing

unde

rlyin

g ca

uses

(in

flam

mat

ion)

Go

for c

heck

-ups

eve

ry 3

-6 m

onth

s (m

ore

frequ

ent i

f as

thm

a is

not

wel

l con

trolle

d)

Ass

ess

asth

ma

cont

rol

Ast

hma

is c

onsi

dere

d to

be

wel

l con

trol

led

if th

e pa

tient

has

: N

o or

min

imal

lim

itatio

n of

dai

ly a

ctiv

ities

N

o m

ore

than

two

occa

sion

s a

wee

k w

hen

asth

ma

sym

ptom

s oc

cur a

nd re

quire

a b

eta-

agon

ist

A P

EF,

if a

vaila

ble,

abo

ve 8

0% p

redi

cted

N

o se

vere

exa

cerb

atio

n (i.

e. re

quiri

ng o

ral s

tero

ids

or a

dmis

sion

to h

ospi

tal)

with

in a

mon

th

Ast

hma

sym

ptom

s on

no

mor

e th

an tw

o ni

ghts

a m

onth

If

any

of th

ese

mar

kers

is e

xcee

ded,

the

patie

nt is

con

side

red

to h

ave

unco

ntro

lled

asth

ma,

and

med

icat

ion

need

s to

be

adju

sted

If

wel

l con

trol

led:

R

emai

n w

ith c

urre

nt tr

eatm

ent f

or 6

m

onth

s A

fter 6

mon

ths,

gra

dual

ly re

duce

dos

age

of m

edic

atio

n to

min

imum

le

vels

N

ever

abr

uptly

sto

p us

ing

inha

led

ster

oids

St

epw

ise

Trea

tmen

t U

se th

e gu

ide

and

incr

ease

trea

tmen

t if s

ympt

oms

are

not w

ell c

ontro

lled

Step

1

Inha

led

beta

ago

nist

(S

albu

tam

ol) a

s re

quire

d (p

rn)

Step

2

Con

tinue

inha

led

Sal

buta

mol

prn

and

ad

d in

hale

d B

eclo

met

ason

e 10

0ug

or

200u

g tw

ice

daily

, or 1

00ug

onc

e or

tw

ice

daily

in c

hild

ren

Step

3

Con

tinue

inha

led

Sal

buta

mol

pr

n an

d in

crea

se th

e do

se o

f B

eclo

met

ason

e to

200

ug to

40

0ug

twic

e da

ily

Step

4

Add

low

-dos

e th

eoph

yllin

e, o

r lo

ng-a

ctin

g be

ta a

goni

sts,

or

incr

ease

dos

e of

inha

led

Bec

lom

etas

one

Step

5

Add

ora

l pre

dnis

olon

e in

the

low

est d

ose

poss

ible

to c

ontro

l sy

mpt

oms

whi

le re

ferr

ing

patie

nt

to lu

ng c

linic

If

Salb

utam

ol in

hale

r is

not a

vaila

ble,

use

tabs

- D

ose

tabl

et S

albu

tam

ol 4

mg

tds

Do

not u

se P

redn

isol

one

tabl

ets

in ro

utin

e ca

re, o

nly

for e

xace

rbat

ions

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

14

AST

HM

A -

TREA

TMEN

T A

ND

FO

LLO

W U

P 2

U

sing

Inha

lers

and

Spa

cers

S

hake

inha

ler

Rem

ove

inha

ler c

ap

Fit i

nhal

er in

to

spac

er, c

heck

the

seal

is ti

ght

Exh

ale

first

and

then

form

a

seal

with

lips

aro

und

mou

thpi

ece

Pre

ss p

ump

and

take

a

deep

bre

ath

from

the

spac

er. O

nly

pum

p on

ce p

er b

reat

h

Hol

d th

at

brea

th a

nd

coun

t to

10

Bre

athe

out

Ast

hma

Atta

cks

1 - A

sses

s Se

verit

y M

ild

Bre

athl

ess

at re

st o

r whi

le ta

lkin

g bu

t can

fini

sh a

sen

tenc

e M

oder

ate

Res

pira

tion

rate

aro

und

25/m

in. h

eart

rate

> 1

00/m

in. c

anno

t fin

ish

a se

nten

ce

Sev

ere

Con

fuse

d or

exh

aust

ed, r

espi

ratio

n ra

te >

30/m

in. h

eart

rate

> 1

20/m

in

STA

RT

TRE

ATM

EN

T A

ND

RE

FER

UR

GE

NTL

Y T

O H

OS

PIT

AL

2- T

reat

men

t S

albu

tam

ol in

hale

r 4 p

uff e

very

20

min

AN

D

Oxy

gen

AN

D

Pre

dnis

olon

tabs

40

mg

O

bser

ve tr

eatm

ent a

nd a

sses

s pa

tient

eve

ry 3

0 m

in to

see

if s

ympt

oms

are

impr

ovin

g

If im

prov

ing,

con

tinue

obs

ervi

ng (i

nclu

de P

EF)

for s

ome

hour

s be

fore

dis

char

ging

. If

dete

riora

ting

whi

le o

bser

ved

or a

fter d

isch

arge

, rep

eat t

reat

men

t and

con

tinue

pre

dnis

olon

e 40

mg

daily

for 5

day

s, a

nd c

onsi

der r

efer

ring

to

hosp

ital.

If in

adeq

uate

resp

onse

and

sev

ere

life

thre

aten

ing

asth

ma

atta

ck:

Add

Am

inop

hylli

ne in

ject

ion.

250

mg

SLO

WLY

ove

r 20

min

whi

le o

rgan

izin

g FA

ST

refe

rral

to h

ospi

tal

Incr

ease

Sal

buta

mol

inha

latio

n

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

15

CO

PD -

TREA

TMEN

T A

ND

FO

LLO

W U

P A

dvis

e th

e Pa

tient

: H

ow to

Liv

e w

ith C

OPD

Exp

lain

wha

t C

OP

D i

s; c

hron

ic l

ung

dam

age,

pe

rhap

s tre

atab

le, b

ut n

ot c

urab

le

Sto

p S

mok

ing

Phy

sica

l exe

rcis

e

Med

icat

ion

for s

ympt

oms

Ens

ure

the

patie

nt u

nder

stan

ds th

at s

mok

ing

and

indo

or a

ir po

llutio

n ar

e th

e m

ajor

ris

k fa

ctor

s fo

r C

OP

D.

Pat

ient

s w

ith C

OP

D m

ust s

top

smok

ing

and

avoi

d du

st a

nd to

bacc

o sm

oke

Kee

p th

e ar

ea w

here

mea

ls a

re c

ooke

d w

ell v

entil

ated

by

open

ing

win

dow

s an

d do

ors;

Coo

k w

ith w

ood

or c

arbo

n ou

tsid

e th

e ho

use,

if p

ossi

ble,

or b

uild

an

oven

in th

e ki

tche

n w

ith a

chi

mne

y th

at

vent

s th

e sm

oke

outs

ide;

Sto

p w

orki

ng in

are

as w

ith o

ccup

atio

nal d

ust o

r hig

h ai

r pol

lutio

n - u

sing

a m

ask

may

hel

p, b

ut it

nee

ds to

ha

ve a

n ap

prop

riate

des

ign

and

prov

ide

adeq

uate

resp

irato

ry p

rote

ctio

n.

St

epw

ise

Trea

tmen

t U

se th

e gu

ide

and

incr

ease

trea

tmen

t if s

ympt

oms

are

not w

ell c

ontro

lled

Mild

In

hale

d S

albu

tam

ol, t

wo

puffs

as

requ

ired,

up

to fo

ur ti

mes

dai

ly

Mod

erat

e If

sym

ptom

s ar

e st

ill tr

oubl

esom

e, c

onsi

der

200

mg

theo

phyl

line

twic

e da

ily

Seve

re

If Ip

ratro

pium

inha

lers

are

ava

ilabl

e, th

ey c

an b

e us

ed in

stea

d of

, or a

dded

to, S

albu

tam

ol, b

ut th

ey a

re m

ore

expe

nsiv

e.

Ex

acer

batio

ns (w

orse

than

usu

al)

If m

ore

sput

um, c

hang

ed to

mor

e ye

llow

/gre

en c

olou

red,

and

/or b

reat

hles

snes

s, te

mp

>38°

C a

nd ra

pid

brea

thin

g ("

bron

chiti

s"),

then

: Tr

eat w

ith a

ntib

iotic

e.g

. Am

oxic

illin

500

mg

3 tim

es a

day

for 1

0day

s O

ral p

redn

isol

one

30 m

g O

D fo

r 7 d

ays

Giv

e H

igh

dose

s of

inha

led

Sal

buta

mol

G

ive

Oxy

gen

if po

ssib

le

Ass

ess

and

cons

ider

refe

rrin

g to

hos

pita

l if c

ondi

tion

is p

oor o

r det

erio

ratin

g.

Ref

er u

rgen

tly to

hos

pita

l/ do

ctor

if (i

n ad

ults

): R

apid

pul

se (>

100/

min

ute)

or

Bre

athi

ng (>

30/m

inut

e) o

r Lo

w B

P (<

90/6

0mm

Hg)

, or

If lip

s ar

e "b

lue"

(cen

tral c

yano

sis)

, or

If co

nfus

ed.

29

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion



CARDIOVASCULAR DISEASE (CVD)

Discuss CVD Risk Explore the client's understanding of his risk of developing cardiovascular disease and the need for change in lifestyle

Invite client to address one lifestyle CVD Risk factor at a time Help the client to plan how to fit the new lifestyle change into the routine of his/her day. Explore the factors that might hinder or support a change in lifestyle Together set reasonable target(s) for the next visit. Record the target(s) in the notes. Diet Physical Inactivity Alcohol Manage Stress Eat a variety of foods in moderation, reduce portion sizes Increase fruit, vegetables and low fat dairy products. Reduce fatty foods: cut off visible animal fat, reduce quantities of cooking oil, avoid margarine. Reduce salty and processed foods including chips and crisps Reduce sugar in food 6

Aim for at least 30 minutes of exercise like brisk walks at least 3 days per week. Increase activities of daily living like walking instead of taking the bus, gardening, housework. Suggest exercise with arms if unable to use legs

7

Limit alcohol intake to a maximum of 2 drinks per day (men) and 1 drink per day (women). If client exceeds these limits, explain the hazards of drinking and explore readiness to change.

9

Take time to perform a relaxing breathing exercise every day Find a creative or fun activity to do. Find somebody who you can confide with.

Smoking Weight

Urge clients to stop smoking

8

Aim for BMI < 25, and waist circumference <88cm (woman) and <102cm (man). Any weight reduction is beneficial, even if targets are not met

Estimate the patient's 10 year risk of getting a CVD

Advise on lifestyle changes If risk > 30% also treat with antihypertensive medication.



Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

17

HYP

ERTE

NSI

ON

- D

IAG

NO

SIS

AN

D T

REA

TMEN

T D

iagn

osis

Pr

oced

ure

1.

Exc

lude

oth

er c

ause

s of

rais

ed b

lood

pre

ssur

e. (S

tress

, Pai

n, F

ever

, Fea

r...)

2.

Pat

ient

has

bee

n re

stin

g at

leas

t 5 m

inut

es b

efor

e ta

king

blo

od p

ress

ure

3.

Arm

in h

eigh

t of h

eart,

and

cuf

f mat

ches

siz

e of

arm

4.

Ta

ke 2

-3 m

easu

rem

ents

with

2 m

inut

es in

bet

wee

n 5.

R

ecor

d on

ly th

e lo

wes

t res

ult

6.

If bl

ood

pres

sure

>14

0/90

TH

EN

Pat

ient

has

to re

turn

on

2 m

ore

occa

sion

s to

repe

at 1

-5. I

f con

stan

t > 1

40/9

0 m

mH

g, D

iagn

ose

HTN

Educ

atio

n, D

iet,

and

Phys

ical

A

ctiv

ity

Mak

e su

re th

e pa

tient

und

erst

ands

wha

t hyp

erte

nsio

n is

and

why

it is

im

porta

nt to

trea

t with

life

styl

e m

odifi

catio

n an

d dr

ugs

(to p

reve

nt

com

plic

atio

ns li

ke s

troke

s, e

tc.)

A h

ealth

y di

et, i

ncre

ased

phy

sica

l act

ivity

, no

smok

ing,

less

alc

ohol

and

less

sa

lt ar

e es

sent

ial.

Life

long

trea

tmen

t is

requ

ired

Nee

d re

gula

r che

ck u

p of

blo

od p

ress

ure

and

bloo

d an

d ur

ine

test

s.

Hyp

erte

nsio

n is

a c

hron

ic c

ondi

tion

that

can

be

treat

ed

with

life

styl

e ch

ange

s an

d m

edic

atio

n. M

ost o

f the

tim

e th

ere

are

no c

lear

sym

ptom

s If

not t

reat

ed H

TN c

an c

ause

stro

ke, h

eart

atta

ck, h

eart

failu

re, v

isio

n de

fect

s an

d ki

dney

failu

re.

Take

the

corr

ect t

able

ts re

gula

rly.

Alw

ays

take

med

icat

ion

as n

orm

al b

efor

e ch

ecki

ng B

P

Dec

isio

n to

Tre

at

Mild

M

oder

ate/

Seve

re

Mal

igna

nt

>1

40 s

ysto

lic a

nd/o

r >90

dia

stol

ic w

ith n

o ot

her s

igni

fican

t ris

k fa

ctor

s >1

70 s

ysto

lic a

nd/o

r >11

0 di

asto

lic o

r mild

hy

pert

ensi

on p

lus

sign

ifica

nt c

ardi

ovas

cula

r ris

k fa

ctor

s (e

.g. d

iabe

tes

mel

litus

, kno

wn

isch

aem

ic h

eart

di

seas

e, p

revi

ous

CVA

/ITA

, str

ong

fam

ily h

isto

ry,

gros

s ob

esity

)

>220

sys

tolic

and

/or >

130

dias

tolic

Li

fest

yle

advi

ce a

nd m

onito

r in

OP

D in

2

mon

ths,

then

6 m

onth

ly

Com

men

ce tr

eatm

ent a

s pe

r alg

orith

m

Adm

it as

pre

viou

s

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

18

HYP

ERTE

NSI

ON

– M

EDIC

ATI

ON

A

nti-

hype

rten

sive

dr

ugs

Ass

ess

CV

D ri

sk a

nd tr

eat w

ith m

edic

atio

n if

10 y

ear r

isk

is >

30%

R

emem

ber t

hat i

t is

mor

e im

porta

nt to

low

er th

e B

P th

an u

sing

a s

peci

fic

drug

and

pre

scrip

tion

shou

ld fo

llow

wha

t is

avai

labl

e.

If B

P s

till t

oo h

igh,

incr

ease

dos

e (to

the

max

imum

reco

mm

ende

d), t

hen

add

othe

r dru

gs a

s re

com

men

ded,

pre

fera

bly

Nife

dipi

ne a

s se

cond

lin

e/dr

ug.

A m

axim

um d

ose

of 4

or m

ore

drug

s m

ay b

e re

quire

d to

get

to.

or n

ear t

o. n

orm

al v

alue

s. B

P c

ontro

l is

criti

cal,

espe

cial

ly in

su

bjec

ts w

ith d

iabe

tes!

A

dd o

ne d

rug

at a

tim

e, s

tarti

ng a

t the

low

er d

ose,

if B

P s

till

rais

ed in

crea

se s

tep

by s

tep

if re

quire

d to

the

max

imum

pr

escr

ibab

le d

ose

or m

axim

um to

lera

ted

dose

.

Step

1

Step

2

Step

3

Step

4

Non

Dia

betic

Th

iazi

de D

iure

tic

Add

CC

B

Add

AC

E in

hibi

tor

Add

bet

a- o

r Alp

ha –

bloc

kers

B

endr

oflu

met

hiaz

ide

(Apr

inox

) 2.

5mg

od (m

ax 5

mg

od) o

r H

ydro

chlo

roth

iazi

de 1

2.5m

g od

(m

ax 5

0mg

od) o

r C

hlor

thal

idon

e 12

.5m

g od

or

Inda

pam

ide

1.5

– 2.

5mg

od

Enc

oura

ge p

otas

sium

inta

ke,

exam

ple

bana

na.

Nife

dipi

ne 2

0mg

od/

Nife

dipi

ne re

tard

20m

g od

(max

80m

g) o

r A

mlo

dipi

ne 5

mg

od (m

ax

10m

g od

)

Cap

topr

il 12

.5m

g bd

(max

50m

g bg

or

tds)

or

Ena

lapr

il 5m

g od

(max

40m

g od

) or

Ram

ipril

2.5

mg

od (m

ax 1

0mg

od) o

r Li

sino

pril

5-10

mg

od (m

ax 2

0mg

od)

Cre

atin

ine

shou

ld b

e ch

ecke

d pr

ior t

o tre

atm

ent a

nd 2

-4 w

eeks

afte

r co

mm

enci

ng A

CE

i.

Bet

a B

lock

er:

Ate

nolo

l 50m

g od

(max

100

mg)

on

ce d

aily

, A

lpha

blo

cker

: D

oxaz

osin

4m

g od

(max

8m

g)

Dia

betic

A

dd A

CE

inhi

bito

r Th

iazi

de D

iure

tic

Add

CC

B

Add

bet

a-bl

ocke

r C

apto

pril

12.5

mg

od

Ben

drof

lum

ethi

azid

e (A

prin

ox) 2

.5m

g od

N

ifedi

pine

MR

20m

g od

A

teno

lol 5

0mg

once

dai

ly.

Cre

atin

ine

shou

ld b

e ch

ecke

d pr

ior

to tr

eatm

ent a

nd 2

-4 w

eeks

afte

r co

mm

enci

ng.

(ther

e is

no

bene

fit a

nd

incr

ease

d ris

k of

hy

poka

laem

ia fr

om u

sing

th

e 5m

g).

Rev

iew

mon

thly

unt

il re

ache

s^ B

P ta

rget

.

Spec

ial

Circ

umns

tanc

es If

preg

nant

M

ethl

dopa

250

mg

bd/td

s (m

ax 3

g da

ily) o

r R

eser

pine

0.1

mg

od (m

ax 0

.25m

g)

AR

Bs

and

AC

Es

are

cont

rain

dica

ted.

Prev

ious

Hea

rt A

ttack

A

CE

I and

bet

a bl

ocke

r A

ngin

a B

eta

bloc

ker o

r CC

B

Ren

al D

isea

se

Ste

p 1:

AC

EI a

nd e

ither

thia

zide

diu

retic

or

CC

B

Ste

p 2:

add

eith

er th

iazi

de d

iure

tic o

r C

CB

S

tep

3: A

dd w

hich

dru

g cl

ass

not u

se in

st

ep 2

Hea

rt fa

ilure

U

se fr

usem

ide

20 m

g O

D (m

ax

80m

g), b

eta

bloc

ker a

nd A

CE

I

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

19

HYP

ERTE

NSI

ON

- FO

LLO

W-U

P R

efer

To

Hos

pita

l

Urg

ent

BP

220

/120

mm

Hg

and

sym

ptom

s:

Hea

dach

e, b

lurr

ed v

isio

n, n

ause

a, w

eakn

ess

of li

mbs

, par

aest

hesi

a, e

tc

Nor

mal

R

efer

ral

BP

>160

/100

mm

Hg

afte

r 6 m

onth

s of

trea

tmen

t M

ake

sure

pat

ient

is a

dher

ing

to tr

eatm

ent,

and

BP

is m

easu

red

corr

ectly

whe

n in

res

t an

d af

ter

havi

ng t

aken

ant

i-HTN

m

edic

atio

n.

Mak

e su

re a

nti-H

TN m

edic

atio

n is

in

corr

ect

dosa

ges

and

tabl

ets

(use

at

leas

t 2

diffe

rent

med

icat

ions

), an

d th

at t

he

ther

apy

has

been

trie

d fo

r sev

eral

mon

ths

Wha

t to

do

Ever

y Vi

sit

ASK

How

are

you

feel

ing?

(in

gene

ral +

spec

ific

sym

ptom

s)

How

hav

e yo

ur B

P m

easu

rem

ents

bee

n si

nce

last

con

trol (

ask

for p

atie

nts

note

book

) Li

fest

yle

rega

rdin

g to

bacc

o, p

hysi

cal a

ctiv

ity, d

iet (

fruits

/veg

etab

les,

sal

t, co

okin

g oi

l) H

ave

you

been

abl

e to

follo

w th

e ad

vice

s gi

ven

rega

rdin

g lif

esty

le c

hang

es?

Do

you

take

med

icat

ion

as p

resc

ribed

? W

hen

did

you

last

take

you

r med

icin

e(s)

? H

ave

you

notic

ed a

ny s

ide

effe

cts

to th

e tre

atm

ent?

A

re th

ere

any

thin

gs in

par

ticul

ar y

ou fi

nd d

iffic

ult r

egar

ding

follo

win

g ad

vice

giv

en/d

o yo

u no

t fee

l com

forta

ble

doin

g?

(Ass

ess

com

plia

nce

to tr

eatm

ent)

Do

you

have

any

que

stio

ns to

you

r con

ditio

n or

the

treat

men

t rec

omm

ende

d?

If B

P in

gen

eral

is <

140/

90 m

mH

g, c

ontin

ue tr

eatm

ent a

s us

ual,

also

if B

P in

the

clin

ic is

hig

her.

If pr

escr

ibed

tre

atm

ent

is n

ot f

ollo

wed

inv

estig

ate

this

ins

tead

of

addi

ng/c

ontin

uing

pre

scrip

tion.

Add

ress

the

und

erly

ing

reas

ons

for

poor

ad

here

nce

to tr

eatm

ent

If pa

tient

has

sto

pped

med

icat

ion

som

e da

ys b

efor

e cl

inic

app

oint

men

t it i

s ex

pect

ed th

at B

P is

hig

h, a

nd y

ou c

anno

t eva

luat

e th

e ef

fect

on

med

ical

trea

tmen

t tha

t was

pre

scrib

ed a

t pre

viou

s vi

sit.

Edu

cate

the

patie

nt o

n w

hy n

ot to

sto

p m

edic

atio

n be

fore

com

ing

to c

linic

, and

to d

o B

P m

easu

rem

ents

regu

larly

and

reco

rd in

not

eboo

k If

side

-effe

cts

of d

rugs

is d

istu

rbin

g, c

hang

e to

ano

ther

dru

g.

If B

P is

con

tinua

lly h

igh

desp

ite fo

llow

ing

to tr

eatm

ent,

add

anti-

HTN

dru

g/in

crea

se d

osag

e. (R

athe

r to

add

a se

cond

med

icin

e th

an in

crea

se

one

to m

axim

um d

osag

e)

Rem

ind

patie

nt to

take

med

icat

ion

ever

y da

y, a

lso

on th

e m

orni

ng o

f clin

ic a

ppoi

ntm

ent.

Ask

pat

ient

to c

heck

BP

regu

larly

at a

nea

rby

heal

th fa

cilit

y (e

.g. O

nce

a w

eek,

and

reco

rd in

his

/her

not

eboo

k un

til n

ext c

linic

app

oint

men

t in

appr

oxim

atel

y on

e m

onth

) If

cont

inui

ng B

P >

160

/100

mm

Hg

desp

ite li

fest

yle

chan

ges,

adh

eren

ce to

ant

ihyp

erte

nsiv

e dr

ug th

erap

y an

d go

od q

ualit

y B

P m

onito

ring

(man

y B

P re

cord

ings

don

e co

rrec

tly) r

efer

to H

TN c

linic

in h

ospi

tal

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

20

HEA

RT

FAIL

UR

E

Def

initi

on:

Failu

re o

f the

hea

rt to

pum

p bl

ood

forw

ard

at s

uffic

ient

rate

to m

eet b

ody

need

s.

Low

car

diac

out

put:

Fa

tigue

Wea

knes

s

Exe

rcis

e in

tole

ranc

e

Ano

rexi

a

Con

gest

ion

of th

e lu

ngs:

Dys

pnoe

a

Par

oxys

mal

noc

turn

al d

yspn

oea

O

rthop

noea

Ex

amin

atio

n m

ay s

how

:

Dis

tens

ion

of th

e ju

gula

r vei

ns in

the

neck

Pitt

ing

oede

ma

of th

e le

gs

E

nlar

ged

tend

er li

ver

C

repi

tatio

ns o

f the

lung

s

Asc

ites

Con

gest

ion

of p

erip

hera

l tis

sues

:

Per

iphe

ral o

edem

a (le

gs)

R

ight

upp

er q

uadr

ant d

isco

mfo

rt (li

ver)

Pul

mon

ary

dise

ase

and

cong

estiv

e he

art f

ailu

re s

hare

man

y si

gns

and

sym

ptom

s an

d so

met

imes

it is

diff

icul

t to

diffe

rent

iate

the

two

dise

ase

stat

es. I

f in

doub

t: re

fer p

atie

nt

P

atie

nts

in a

cute

hea

rt fa

ilure

sho

uld

imm

edia

tely

be

refe

rred

to h

ospi

tal f

or fu

rther

man

agem

ent a

nd g

ive

Lasi

x 40

mg.

Th

e pa

tient

sho

uld

be p

ropp

ed u

p or

sea

ted

to re

duce

the

cong

estio

n of

the

lung

s an

d de

crea

se th

e br

eath

less

ness

If

ava

ilabl

e co

nsid

er o

xyge

n su

pple

men

tatio

n.

A

DVI

SE T

O T

HE

PATI

ENT

Pat

ient

s w

ith c

hron

ic h

eart

failu

re n

eed

to ta

ke m

edic

atio

n ev

ery

day

as p

resc

ribed

by

spec

ialis

ts.

Enc

oura

ge th

e pa

tient

to b

e ph

ysic

ally

act

ive

acco

rdin

g to

abi

lity,

e.g

. Wal

king

, cyc

ling.

E

ncou

rage

regu

lar c

heck

ups

even

whe

n on

med

icat

ion

Alw

ays

take

med

icin

e as

pre

scrib

ed b

efor

e go

ing

to c

linic

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

21

STR

OK

E U

sual

ly a

cute

eve

nts!

! D

ue to

a b

lock

age

that

pre

vent

s bl

ood

from

flow

ing

to th

e br

ain:

A b

uild

-up

of fa

tty d

epos

its o

n th

e in

ner w

alls

of t

he b

lood

ves

sels

Ble

edin

g fro

m a

blo

od v

esse

l in

the

brai

n

Fo

reig

n bo

dies

from

oth

er p

arts

of t

he b

ody

(e.g

. blo

od c

lots

)

Com

mon

sym

ptom

s in

clud

e su

dden

ons

et o

f:

� W

eakn

ess

of th

e fa

ce, a

rm, o

r leg

, mos

t ofte

n on

one

sid

e of

the

body

�

Num

bnes

s of

the

face

, arm

, or l

eg, e

spec

ially

on

one

side

of t

he b

ody

�

Con

fusi

on

� D

iffic

ulty

spe

akin

g or

und

erst

andi

ng s

peec

h

� D

iffic

ulty

see

ing

with

one

or b

oth

eyes

�

Diff

icul

ty w

alki

ng, d

izzi

ness

, los

s of

bal

ance

or c

oord

inat

ion

�

Sev

ere

head

ache

with

no

know

n ca

use

�

Fain

ting

or u

ncon

scio

usne

ss.

Peop

le e

xper

ienc

ing

thes

e sy

mpt

oms

shou

ld b

e re

ferr

ed to

hos

pita

l im

med

iate

ly

LIPI

D C

ON

TRO

L C

heck

lipi

ds:

At t

he b

egin

ning

in p

atie

nts

with

CV

D

At t

hree

mon

ths

in p

atie

nts

with

dia

bete

s bu

t with

out C

VD

and

Y

early

ther

eafte

r. H

igh

is:

� To

tal c

hole

ster

ol >

5.2

mm

ol/l

�

LDLc

> 2

.6 m

mol

/l or

�

HD

Lc <

1.1

mol

/l

� Tr

igly

cerid

es >

1.7

mm

ol/l

Educ

atio

n, d

iet a

nd a

ctiv

ity

Edu

cate

and

cou

nsel

on

heal

thy

eatin

g an

d da

ily a

ctiv

ity, a

s ab

ove

for

diab

etes

and

hig

h B

P, t

hen

reas

sess

afte

r thr

ee m

onth

s, re

peat

lipi

ds.

Lipi

d lo

wer

ing

drug

s

� If

lipid

s ch

oles

tero

l (LD

L) re

mai

n hi

gh a

fter 3

mon

ths,

then

refe

r/tre

at.

� G

ive

a st

atin

e.g

. Ato

rvas

tatin

or S

imva

stat

in 2

0mg

daily

(max

40m

g).

� If

fast

ing

trigl

ycer

ides

> 1

.7m

mol

/l), a

dd fe

nofib

rate

or c

lofib

rate

. Or

� If

only

trig

lyce

ride

rais

ed th

en fi

brat

e al

one

(with

out a

sta

tin)

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

22

DIA

BET

ES -

DIA

GN

OSI

S 1

C

onsi

der S

cree

ning

for D

M if

: C

onsi

der D

M if

One

or M

ore

of th

e Fo

llow

ing:

A

ge >

40

year

s O

bese

or l

arge

r wai

st

His

tory

of d

iabe

tes

in th

e fa

mily

K

now

n hy

perte

nsio

n H

isto

ry o

f IH

D (a

ngin

a or

MI)

or

Stro

ke

BM

I > 3

0 W

aist

> 1

02 c

m m

en, >

88

cm w

omen

P

regn

anci

es:

His

tory

of g

esta

tiona

l dia

bete

s,

Larg

e ba

by >

4kg,

or

Stil

lbirt

h in

pre

viou

s pr

egna

ncie

s

Freq

uenc

y of

urin

atio

n, e

ven

at n

ight

, S

ore

vagi

na, d

isch

arge

, thr

ush,

pen

is it

chy

Infe

ctio

ns, r

ecur

rent

e.g

.: B

oils

, stie

s,

absc

ess,

unh

eale

d w

ound

s A

bnor

mal

sen

satio

n of

the

feet

(pin

s an

d ne

edle

s, ti

nglin

g, b

urni

ng s

ensa

tion)

Thirs

t, w

antin

g to

drin

k P

rogr

essi

ve v

isua

l los

s A

thle

tes

feet

, itc

hy ra

sh in

flex

ures

(in

tertr

igo)

U

nint

entio

nal,

unex

plai

ned

wei

ght l

oss

desp

ite g

ood

appe

tite

NO

TE

Dia

gnos

e D

M if

: If

bloo

d gl

ucos

e te

st n

ot a

vaila

ble,

test

urin

e gl

ucos

e If

nega

tive

for s

ugar

and

hav

ing

clas

sica

l sym

ptom

s:

Adv

ise

to g

o an

d ch

eck

fast

ing

bloo

d su

gar e

lsew

here

If

posi

tive

for s

ugar

(in

bloo

d) a

nd c

lass

ical

sym

ptom

s di

agno

se D

M

Giv

e lif

esty

le a

dvis

es a

nd re

fer t

o D

M c

linic

for c

heck

up in

two

mon

ths

(ear

lier i

f sym

ptom

s ar

e se

vere

). D

o no

t dia

gnos

e D

M in

acu

tely

ill p

atie

nts

with

out c

lass

ical

sym

ptom

s

RB

GR

BG

>11

.0

mm

ol/l

RB

G <

7.8

mm

ol/l

RB

G 7

.8 -

11.0

mm

ol/l

2HR

Sym

ptom

s?R

epea

ted?

2HR

> 1

1.0

mm

ol/l

DIA

BET

ES

OG

TT2H

R

NO

DIA

BET

ES

FBG

FBG

>7.

0m

mol

/lFB

G 6

.1 -

6.9

mm

ol/l

FBG

< 6

.1m

mol

/l

2HR

< 7

.8m

mol

/l

IGT

2HR

7.8

- 11

.0m

mol

/l

Yes

No

Whi

ch re

sults

sho

uld

resu

lt in

refe

rral

to D

M c

linic

?

Urin

e di

pstic

ks +

ve K

eton

es +

+ M

icro

scop

ic h

aem

atur

ia (o

nce

infe

ctio

n ex

clud

ed) o

r cas

ts

Pro

tein

uria

on

2 or

mor

e oc

casi

ons

Pre

gnan

cy

BP

> 2

20/1

20 m

mH

g un

treat

ed, o

r BP

> 1

30/8

0 m

mH

g de

spite

m

axim

um tr

eatm

ent

Pai

n in

the

calf

whe

n w

alki

ng (s

uspe

ct p

erip

hera

l vas

cula

r dis

ease

) H

isto

ry o

f che

st p

ain

on e

xerti

on (s

uspe

ct A

ngin

a pe

ctor

is)

Unc

ompe

nsat

ed h

eart

failu

re

Vis

ion

loss

(sus

pect

retin

opat

hy, c

atar

act)

FBG

> 13

mm

ol/L

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

23

DIA

BET

ES -

DIA

GN

OSI

S 2

IFG

Exp

lain

that

if IF

G is

a p

redi

ctor

of D

M b

ut it

is

NO

T D

M

Info

rm p

atie

nt th

ey m

ay d

evel

op d

iabe

tes

in

futu

re b

ut th

is c

an b

e de

laye

d / a

void

ed b

y he

alth

y be

havi

or.

Die

tary

adv

ises

: A

t lea

st 6

pie

ces

of v

eget

able

/frui

t a d

ay,

redu

ce u

se o

f sal

t, su

gar a

nd c

ooki

ng o

il,

eat w

hole

gra

in,

advi

se o

n a

bala

nced

pla

te a

nd p

ortio

n si

ze)

Phy

sica

l act

ivity

dai

ly (a

t lea

st h

alf a

n ho

ur a

da

y)

Ass

ess

patie

nts

risk

fact

or p

rofil

e

Che

ck F

BG

onc

e a

year

to m

onito

r pro

gres

s

Adv

ise

lifes

tyle

cha

nges

( 5

onw

ard)

Wei

ght c

ontro

l (w

eigh

t los

s if

BM

I > 2

5 or

w

aist

circ

umfe

renc

e ab

ove

88 c

m (w

omen

) or

102

cm (m

en))

Mod

erat

ion

if dr

inki

ng a

lcoh

ol (m

ax 1

-2

units

/day

)

If pr

egna

nt re

fer t

o ho

spita

l.

DM

Ass

ess

patie

nt's

risk

fact

or p

rofil

e an

d ad

vice

Adv

ise

life

styl

e ch

ange

s

Pro

vide

die

tary

cou

nsel

ing

( 6

)

Ass

ess

for c

ompl

icat

ions

:

Ask

abo

ut c

hang

e to

vis

ion/

visi

on lo

ss: u

se

visi

on c

hart,

Look

for c

atar

act a

nd re

fer f

or re

tina

exam

inat

ion.

Ass

ess

the

feet

(ask

abo

ut n

umbn

ess,

pin

s an

d ne

edle

s an

d ch

eck

for s

ensa

tions

, foo

t pul

ses,

an

d fo

otw

ear)

Inqu

ire a

bout

loss

of l

ibid

o, p

oor e

rect

ions

and

in

cont

inen

ce o

f urin

e or

sto

ol.

DM

Pa

tient

Ed

ucat

ion

Rei

nfor

ce m

essa

ges

at a

ll ap

poin

tmen

ts.

Use

loca

l, si

mpl

e an

d cl

ear l

angu

age.

A

sk p

atie

nt to

repe

at k

ey p

oint

s an

d as

k if

they

hav

e an

y qu

estio

ns.

Info

rm p

atie

nt:

Dia

bete

s is

whe

n th

e bo

dy c

anno

t pro

perly

use

the

food

s w

e ea

t, es

peci

ally

sug

ar d

ue to

la

ck o

f ins

ulin

. Tr

eatm

ent i

s lif

e-lo

ng a

nd n

eed

adju

stm

ent f

rom

tim

e to

tim

e A

per

son

cann

ot g

ive

diab

etes

to a

noth

er p

erso

n.

Blo

od s

ugar

con

trol,

a he

alth

y di

et a

nd in

crea

sed

phys

ical

act

ivity

are

ess

entia

l. P

atie

nts

with

dia

bete

s ca

n de

velo

p hy

perte

nsio

n an

d th

e ot

her w

ay ro

und,

esp

ecia

lly if

ov

erw

eigh

t. H

igh

bloo

d su

gars

in p

regn

ancy

can

dam

age

unbo

rn b

aby.

Add

add

ition

al in

form

atio

n as

requ

ired

e.g.

cha

nge

in

med

icat

ion.

G

ive

the

patie

nt a

n ed

ucat

ion

leaf

let.

Ref

er to

hea

lth e

duca

tor i

f ava

ilabl

e.

If bl

ood

gluc

ose

is n

ot c

ontro

lled,

it c

an c

ause

bl

indn

ess,

kid

ney

failu

re, h

eart

dise

ase,

stro

kes,

di

seas

e of

blo

od v

esse

ls, i

mpo

tenc

e, le

g ul

cers

. Tr

eatm

ent i

nclu

des

diet

, exe

rcis

e, re

gula

r clin

ic v

isits

E

ach

diab

etic

cas

e is

indi

vidu

al a

nd m

edic

atio

n ca

nnot

be

shar

ed

Dia

bete

s an

d hy

perte

nsio

n ar

e lin

ked

dise

ases

. If

cons

ider

ing

beco

min

g pr

egna

nt it

is im

porta

nt to

se

e a

spec

ialis

t bef

ore

conc

eptio

n

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

24

DIA

BET

ES –

TR

EATM

ENT

AN

D F

OLL

OW

UP

1

Dia

gnos

ed w

ith D

M

Trea

tmen

t goa

ls a

re a

s fo

llow

s

NO

TE

Hea

lth e

duca

tion

(foot

car

e. h

ypog

lyce

mia

, hyp

ergl

ycem

ia)

Life

styl

e ad

vise

s (d

iet,

exer

cise

, tob

acco

and

alc

ohol

use

) R

evie

w in

1 m

onth

2

5

FB

G <

7.0

mm

ol/l

RB

G <

7.8

mm

ol/l

HB

A1C

< 6

.5%

Fe

w o

r no

hypo

gylc

aem

ic e

piso

des

If

preg

nant

refe

r im

med

iate

ly.

If FB

G >

12.

0 go

dire

ctly

to

step

2

Step

1

Che

ck F

BG

+ B

P

Ask

abo

ut li

fest

yle,

mot

ivat

ion

and

supp

ort

Rev

iew

in 1

mon

th

Step

2

Exp

lain

the

need

for m

edic

atio

n to

geth

er w

ith li

fest

yle

mod

ifica

tion

Met

form

in 2

50m

g B

D (M

axim

um 7

50m

g B

D)

Rev

iew

in 1

mon

th

FBG

<6.1

FB

G>6

.1 b

ut lo

wer

than

at

diag

nosi

s FB

G >

13

If no

impr

ovem

ent:

Incr

ease

to 5

00m

g B

D

Rev

iew

in 1

mon

th

If Im

prov

ed F

BG

: C

ontin

ue m

edic

atio

n R

evie

w in

3m

onth

s

Exp

lain

that

FB

G =

non

di

abet

ic, b

ut im

porta

nce

of:

Non

-sug

ar d

iet

Con

tinue

life

styl

e R

evie

w in

6m

onth

s w

ith F

BG

Con

tinue

life

styl

e A

sses

s pr

oble

m a

reas

and

of

fer h

elp

Rev

iew

in 3

mon

ths

with

FB

G

Pro

ceed

to

Ste

p 2

FBG

N

ot im

prov

ed:

Add

Glib

encl

amid

e (D

aoni

l) 2.

5 m

g B

D

(Max

imum

dos

e 10

mg

BD

) R

evie

w in

1 m

onth

If

no im

prov

emen

t R

efer

to D

M c

linic

for c

onsi

dera

tion

of

insu

lin

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

25

DIA

BET

ES -

FQLL

OW

UP

AN

D R

EFER

RA

L A

t Eve

ry V

isit

to C

linic

: O

nce

ever

y tw

o ye

ars:

A

sk a

bout

gen

eral

wel

lbei

ng. s

ympt

oms

and

adhe

renc

e to

trea

tmen

t A

sk a

bout

any

pro

blem

s re

late

d to

trea

tmen

t (lif

esty

le o

r med

icin

es)

Test

FB

G

Mea

sure

wei

ght,

heig

ht a

nd w

aist

circ

umfe

renc

es

Che

ck b

lood

pre

ssur

e D

ieta

ry c

ouns

elin

g A

dvis

e lif

esty

le c

hang

es

Dis

cuss

kno

wle

dge

and

belie

fs o

f dia

bete

s, fo

ot c

are,

glu

cose

mon

itorin

g P

rovi

de c

ouns

elin

g ab

out c

ontra

cept

ion

and

prov

ide

prec

once

ptio

n ad

vice

Eye

exa

min

atio

n at

refe

rral

leve

l (ac

cord

ing

to n

ew W

HO

gui

delin

es)

FAQ

H

ow m

uch

shou

ld F

BG

impr

ove

in b

etw

een

visi

ts?

Usu

ally

it d

epen

ds o

n cl

inic

al im

prov

emen

t and

2-3

mm

ol/l

will

do

If FB

G h

as n

ot im

prov

ed to

whi

ch c

ut-o

ff w

ithin

6 m

onth

s sh

ould

med

icat

ion

be s

tart

ed?

Sta

rt m

edic

atio

n on

the

basi

s of

dec

reas

ing

the

wei

ght,

wor

seni

ng o

r no

chan

ge o

n sy

mpt

oms,

or F

BS

mor

e th

an 1

0 m

mol

/l If

alre

ady

star

ted

on M

etfo

rmin

at d

iagn

osis

but

life

styl

e m

odifi

catio

ns a

re

succ

essf

ul, w

eigh

t red

uces

and

FB

G is

impr

ovin

g, s

houl

d M

etfo

rmin

be

redu

ced

or d

isco

ntin

ued?

It

can

be re

duce

d st

epw

ise,

then

dis

cont

inue

Onc

e pe

r yea

r:

Urin

e pr

otei

n (d

ipst

ick)

and

foot

exa

min

atio

n

Ref

erra

l to

DM

Clin

ics

Wha

t sho

uld

be u

rgen

tly R

efer

red

R

efer

ral w

ithin

48/

72 h

ours

Alte

red

cons

ciou

snes

s w

ith to

o lo

w/h

igh

gluc

ose

(<4m

mol

/L o

r 20

mm

ol/L

) C

hest

pai

n an

d br

eath

less

ness

(ang

ina,

hea

rt at

tack

or h

eart

failu

re)

Slu

rred

spe

ech,

one

-sid

ed w

eakn

ess

(stro

ke/tr

ansi

ent i

scha

emic

atta

ck)

Sev

ere

infe

ctio

n in

dia

betic

pat

ient

incl

udin

g le

g in

fect

ion/

ulc

er

All

wom

en w

ith p

re-e

xist

ing

Type

1 o

r Typ

e 2

Dia

bete

s w

ho

beco

me

preg

nant

W

omen

who

dev

elop

Ges

tatio

nal D

iabe

tes

Sam

e D

ay R

efer

ral

O

ther

s (o

rder

ed h

ighe

st->

low

est p

riorit

ies)

New

ly d

iagn

osed

chi

ldre

n w

ith d

iabe

tes

Sus

pect

ed n

ewly

dia

gnos

ed ty

pe 1

dia

bete

s es

peci

ally

urg

ent i

n th

ose

who

pre

sent

w

ith k

eton

uria

and

/or v

omiti

ng

Pat

ient

s w

ith in

fect

ed, n

ecro

tic o

r gan

gren

ous

foot

ulc

erat

ion

or s

uspe

cted

cha

rcot

foot

. S

udde

n lo

ss o

f vis

ion

P

atie

nts

seve

rely

at r

isk

of d

iabe

tic fo

ot w

ound

R

etin

opat

hy/re

duce

d vi

sual

act

ivity

P

atie

nts

pres

entin

g w

ith p

ersi

sten

t pro

tein

uria

W

omen

with

Typ

e 1

or T

ype

2 D

iabe

tes

cont

empl

atin

g pr

egna

ncy

Rec

urre

nt h

ypog

lyca

emia

Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tes

Ass

ocia

tion


Min

istr

y of

Hea

lth

& So

cial

Wel

fare

and

Tan

zani

a D

iabe

tic

Ass

ocia

tion

26

DIA

BET

ES -

TREA

TMEN

T A

ND

FO

LLO

W U

P 3

Si

gns

of H

ypog

lyce

mia

Sign

s of

Hyp

ergl

ycem

ia

Hyp

ogly

caem

ia is

whe

n bl

ood

gluc

ose

is u

nder

3 m

mol

/l Th

e si

gns

and

sym

ptom

s in

clud

e th

e fo

llow

ing:

Freq

uent

urin

atio

n Ti

redn

ess

Sto

mac

h pa

in, n

ause

a an

d vo

miti

ng

Ver

y dr

y m

outh

U

ncle

ar v

isio

n

Incr

ease

d th

irst

Dry

itch

ing

skin

S

hortn

ess

of b

reat

h F

eelin

gs o

f hu

nger

H

eada

che

Tr

emor

s P

rofu

se s

wea

ting

Inco

here

nt s

peec

h

Tac

hyca

rdia

A

nxie

ty

Irri

tabi

lity

Wea

knes

s T

ired

ness

Diz

zine

ss

Con

fusi

on

Trou

ble

conc

entra

ting

Agg

ress

iven

ess

Unc

onsc

ious

ness

/com

a

It is

im

porta

nt t

o id

entif

y th

e ca

use

of h

ypog

lyca

emia

and

int

erve

ne.

Com

mon

cau

ses

incl

ude:

E

aten

less

food

than

usu

al, s

kipp

ing

mea

ls, i

rreg

ular

eat

ing

patte

rns

Eat

en d

iffer

ent f

ood

than

usu

al, e

.g. o

nly

soup

or m

eat

Wei

ght l

oss

lead

ing

to n

eedi

ng le

ss m

edic

ine

Take

n a

high

er d

ose

of m

edic

ine

than

pre

scrib

ed

Hig

her l

evel

of p

hysi

cal a

ctiv

ity th

an u

sual

A

lcoh

ol in

take

It

is i

mpo

rtant

to

inve

stig

ate

and

rect

ify t

he r

easo

n w

hy t

he b

lood

sug

ar i

s to

o hi

gh. C

omm

on c

ause

s in

clud

e:

Eat

en to

o m

uch

or n

ot th

e rig

ht ty

pe o

f foo

d Th

e cu

rren

t med

icat

ion

is n

ot s

uffic

ient

any

long

er

Forg

otte

n to

take

med

icat

ion

as p

resc

ribed

Le

vel o

f phy

sica

l act

ivity

has

bee

n to

o lo

w

Dis

ease

e.g

. an

infe

ctio

n in

the

body

Illn

ess

e.g.

dep

ress

ion

or m

enta

l st

ress

Che

ck B

G

If B

G <

3.0:

Che

ck R

BG

R

BG

>11

.0:

If R

BG

abo

ve 1

8 an

d K

eton

es:

Giv

e su

gar p

er o

ral

Trea

tmen

t Sup

port

If

not k

now

n di

abet

ic a

lso

chec

k ur

ine-

keto

ne)

Find

rea

son

for

hype

r (o

ut

of d

rugs

, adh

eren

ce)

Adj

ust t

reat

men

t S

ee p

atie

nt w

ithin

1 m

onth

Ref

er to

hos

pita

l G

ive

i/v N

/S 2

ltr 1

st h

our

Edu

cate

pat

ient

s, fa

mily

and

pro

vide

rs a

bout

hyp

ogly

cem

ia, i

ts c

ause

s,

and

appr

opria

te m

itiga

tion

tech

niqu

es

R

amad

han

and

diab

etes

Fa

stin

g fo

r pat

ient

s w

ith d

iabe

tes

repr

esen

ts a

n im

porta

nt p

erso

nal d

ecis

ion.

S

houl

d be

dis

cuss

ed w

ith h

eath

per

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DIABETES - INSULIN PRESCRIPTION

Insulin (refer to doctor to initiate)

� Insulin is started when not controlled on oral drugs. When adding insulin, metformin can be continued, but sulphonylurea is phased out.

� When initiating insulin review after 3 days, weekly, then monthly, then when controlled 3 monthly.

� Do a FBG at every visit, also checking use of insulin etc. � When monitoring, if available ask/ ring the doctor for advice. � If problems, and feasible for the patient to go, refer to hospital

Things to tell your patients taking insulin � Patients are more likely to gain weight. � Patients are more likely to get low glucose (hypos) with insulin. � It is important to take insulin even if unwell or not eating, but the dose may need to

be altered Before starting insulin Consider: � Is patient/treatment supporter willing and capable to start insulin?

� Is vision good, are hands able to use appropriate device? � Can insulin be stored at home? (Cool dry place/fridge away from heat sources) � Is glucose monitoring at clinic or home available? � Is the injection site known?

If No: If yes, give in the following order

until BG controlled: Give long acting insulin once a day

� Long acting OD � Mix of short/intermediate acting BD � Short acting TDS � Short acting TDS and long acting OD.

Insulin dosage and frequency depends on:

Sites for injection (as preferred by patient):

� Their job, meal and sleep times, weekend activities, etc.

� If regular meals and activity give insulin twice a day (BD)

� If not, insulin TDS or even QDS may be needed

� Weight – heavier people need more insulin

� Duration/phase of diabetes – more insulin if advanced diabetes

� When combining oral hypoglycaemic drugs and insulin, the long acting insulin once a day is preferred choice

� Subcutaneous injection into stomach; or � Outer part of thighs, � Upper arm (deltoid area), � Upper outer buttocks � Rotate injection sites to reduce insulin injection site

damage � Any site: inject at 90 degree angle (or at 45 degrees if

patient is thin) � Increased physical activity – reduce the insulin � Infections/ illnesses – increase insulin (but reduce

insulin if reduced food intake e.g. as reduced appetite) � Other treatments (beta blockers etc)

The average daily insulin requirement is 0.5 – 0.6 units/kg. Start with 0.2 units/kg/day, increase by 2 units every week. If more than a single daily insulin dose is required, consider: 2/3 of the daily dose in the morning, 1/3 in the evening 2/3 intermediate/long acting, 1/3 short acting/soluble

If doses are higher than 0.75 units/kg/day exclude: � Overweight � Low physical activity � inappropriate insulin (measurement, expiry, storage,

injection techniques) � Overdose especially if fluctuating blood glucose levels.




DIABETES - DIABETIC FOOT Diabetes Foot care At diagnosis and annual review or frequently where known problem: � Inspect both feet for any ulcers or deformity � Test foot sensation with monofilament and tuning fork/gross sensation � Palpate for foot pulses � Inspect footwear � If any ulcer or new foot deformity, refer to hospital/doctor. Patients with reduced sensation or absent foot pulses are high risk of acquiring foot disease Foot care education � Do not walk with bare feet � Make sure shoes fit properly and do not cause shoe bites. Advise to buy footwear in the evening when

foot size is biggest � Wash and dry your feet regularly � Check your feet regularly for any broken skin. If any new broken skin, go to health facility to be seen,

even if painless � Do not cut calluses or corns – go to the clinic for treatment If you have numbness in feet, be careful near fires and hot water.

DIABETES IN CHILDHOOD

Presentation

� Whereas adults may report feeling tired and lethargic, children may simply not want to work or play.

� Polyuria and nocturia may present as bedwetting or enuresis. � Symptoms are often abrupt and illness is often severe with vomiting, stomach pain,

rapid/laboured breathing and altered level of consciousness. � If glucose and ketones are present in urine, treatment is urgent and the child should

be treated the same day to avoid the progression of ketoacidosis.

Management

� The main type of diabetes in childhood is Type 1 diabetes. � Presentation in DKA is very common and only effective treatment is insulin and not

oral drugs or traditional medicines. � Children’s insulin requirements change frequently, due to growth in size, puberty and

the demands of school, sport and work. � Insulin dosage is based on weight. As children grow rapidly, their insulin doses need

to be adjusted at each clinic visit; every few months at least. � Insulin requirements increase during the pubertal growth spurt and then decrease

back to normal adult levels as growth is completed. � Children with diabetes and their families need constant re-education as the child

becomes older and more able to understand and develop diabetes self-care skill. � Good control is essential to avoid acute complications which can be frequent and are

deadly and to prevent long term complications. � The patient, parents, friends, neighbours, school and healthcare workers must all be

working together as a team to provide the child with practical, emotional and moral support where needed.

� Dietary considerations include requirements for growth and childhood activities including play.




SEVERELY ILL PATIENTS

Signs of Severe Illness: Pulse >125 bpm Dry lips/tongue, sunken eyes (dehydration) Temperature >40°C Increased respiratory rate (pneumonia/ketoacidos) Wheezing or crepitations Systolic BP <90 mmHg (shock/ heart failure)

Refer urgently to hospital if one or more of: Became unwell rapidly Rapid breathing, dry lips/mouth (dehydration) Reduced consciousness Ketones in the urine (ketoacidosis) Abdominal pain with vomiting Rapid weight loss

While arranging transfer to hospital treat symptomatic the following:

If dehydrated: If suspected anaphylaxis (SBP < 90 mmHg and relevant exposure):

If conscious give frequent drinks, oral re-hydration solution or IV Ringer Lactate solution if reduced consciousness.

Monitor airway Give adrenaline 0.5 mg IM (side of thigh). If no response, repeat every 5 mins max 3 times Give hydrocortisone 100-300 mg IV Give IV fluids Itr NS rapid and Itr NS slow infusion

If RBG <=2.8 mmol/l: If signs and symptoms of heart failure:

If able to drink give one large tablespoon of sugar mixed in water or 1 glass of fruit juice, honey or a sugary drink. If no response within 15 minutes, repeat If unconscious/unable to drink, give 50 ml 50% glucose IV if feasible.

Sit patient upright Give frusemide 40 mg as single doses If chest pain, radiating to (left) arm or chin: Give aspirin 300 mg as single dose (unless history of Gl bleeding) Do not give Diclofenac, Diclopar or any other NSAID

If urine ketones +++ and blood glucose >13.9 mmol/L (in known or suspect Diabetic patient)

Fever > 38°C and/or stiff neck

Give 1 Itr NS as rapid infusion, and another 1/2 Itr NS as slow infusion Give short acting (rapid) insulin 10 IU IM if available and only if certain of the diagnosis DKA

Consider meningitis or cerebral malaria and start appropriate treatment with antibiotics

If convulsions/seizure in pregnancy: Paralysis

Give magnesium sulphate 4 g IV over 5-15 mins If not available, or as supplement, give diazepam 10 mg rectally Secure airways

Maintain a free airway before and during transport to hospital 25




SEVERELY ILL PATIENTS – THE UNCONCIOUS

The Unconscious or Semi Conscious Patient There are many causes (including diabetes and stroke) but all patients require attention before referral, as in table below

1st Group of Actions

A) AIRWAY Maintain airway by chin lift or jaw thrust by the head tilt manoeuvre If no free airway: check for alien body in throat and remove it

B) BREATHING If no spontaneous breathing, assist with ventilation If wheezes, administer Salbutamol

C) CIRCULATION Stop any bleeding by compression Insert IV line for fluid if hypovolaemic

D) DRUGS

AVPU Is the patient Awake? Responds to Voice? To Pain? Or completely Unresponsive?

Place unconscious patient in lateral recovery position unless neck trauma suspected

History

2nd Group of Actions

Diagnosis of epilepsy, hypertension, diabetes

Alcohol / substance abuse Insect sting or snake bite Recent trauma Convulsions Known allergy Medicines taken

Measure

3rd Group of Actions

Blood pressure

Pulse

Respiration rate

Temperature

Blood glucose Check For 4th Group of Actions

One sided weakness Seizures/convulsions Stiff neck Advanced pregnancy Swelling of lips, tongue or neck Informative skin lesions (bites, infections, pettechia etc




TREATMENT SUPPORTER Explain to patient why a treatment supporter is important:

� Treatment is life-long, support is essential.

� It can be difficult to remember to take tablets regularly, but it is vital to continue treatment.

� A treatment supporter is someone they can talk to easily and who will encourage them to continue with treatment.

� It is their choice who will be their treatment supporter.

� The treatment supporter will be called if they cannot be contacted or if there is a problem

Discuss who would be the best treatment supporter; it must be someone concerned, trusted and committed to providing support.

Help the patient choose someone e.g. family member, friend, community volunteer or home based care volunteer. If patient cannot decide, suggest someone.

Record name, address and mobile phone number of patient and treatment supporter on the patient’s treatment card.

Ask the patient to bring treatment supporter with them for all clinic visits, to learn about the illness, treatment and their role.

Advise treatment supporter to:

� Meet with the patient often, try to make this a enjoyable time. If possible, meet at the time the patient takes their tablets to see them taking the tablets as prescribed.

� Look at tablet pack to check the patient is taking tablets correctly.

� Inform health worker if the patient stops taking the tablets.

� Encourage the patient to be active, eat healthily, stop smoking as needed and attend appointments

Appointment reminders

� If an individual fails to attend a review appointment, take action.

� Phone patient and encourage them to return.

� Phone treatment supporter and ask them to remind patient.

� Ask someone e.g. CHW to home visit if patient does not return.

� If patient is not adhering to treatment or attending appointments:

� Do not criticise.

� Discuss any concerns or difficulties.

� Encourage the patient and treatment supporter

� Remind patient of treatment contract and the importance of continued medication.

� If patient has stopped medication:

� Check BP (see p12) and do lab tests as appropriate.

� If results are high, review and start again as if new patient




Medicine: Contra-Indications and Major Side Effects Medicine Contraindication Major common side effects Thiazide diuretic

Gout Low potassium leading to e.g. muscle weakness Impaired glucose tolerance/diabetes Impotence

Beta blockers (BB)

Asthma Chronic obstructive pulmonary disease (COPD) Insulin dependent diabetes Uncompensated heart failure Second and third degree heart block Bradycardia <50/min Raynaud's syndrome

Fatigue Abdominal discomfort, constipation, diarrhoea Worsening of congestive heart failure Heart rate < 50 per minute Insulin resistance/hyperglycaemia Dyslipidaemia Erectile dysfunction (impotence)

ACE-inhibitor (ACEi)

Pregnancy Hyperkalaemia Bilateral renal artery stenosis

Increase in creatinine levels Dry irritative cough Headache, dizziness, sleep disturbances Abdominal cramps, nausea or vomiting Diarrhoea, constipation/foetal abnormalities

Ca-Channel blocker

Congestive heart failure Nausea, general discomfort Ankle swelling Constipation Headache

(CCB) Treatment with rifampicin (TB treatment)

Aspirin (Antiplatelet)

Peptic ulcer (and caution if dyspepsia) Severe heart failure Untreated severe hypertension

Stomach pain, heartburn Nausea and vomiting, diarrhea Gastrointestinal bleeding Headache, sleep disturbances Aspirin-induced asthma

Biguanide (Metformin)

Kidney failure Severe hepatic failure Hypoxic tissue (e.g Ml) Surgery in near future Pregnancy or breast feeding

Diarrhoea, nausea, vomiting Abdominal discomfort Reduced appetite, weight loss

Sulphonylureas Pregnancy Surgery in near future

Risk of (prolonged) hypoglycaemia Skin rash, itch

Statins Liver disease Affection of liver function Abdominal discomfort, flatulent, diarrhoea Headache Muscle cramps, arthritis, myalgia Hyperglycaemia

Weight reducing drug (Orlistat)

Abdominal pain, flatulent, incontinence for faeces, fatty diarrhoea Restlessness




Useful Resources WHO Model Formulary 2008 www.who.int/seletcion_medicines/list/WMF2008.pdf British National Formulary: http://www.bnf.org/bnf/ WHO Integrated Management of Adolescent and Adult Illness (IMAI)

- Acute care: www.who.int/hiv/pub/imai/en/IMAIAcuteCareRev2.pdf

- General principles of good chronic care: www.who.int/hiv/pub/imai/generalprinciples082004.pdf




Acronyms ACEi Angiotensin converting enzyme inhibitors ADA American Diabetes Association ARB Angiotensin receptor blocker BD Twice a day BG Blood glucose BP Blood pressure bpm Beats per minute CCB Ca-Channel blocker CHW Community health worker CRCT Cluster randomised controlled trial CVD Cardiovascular disease eGFR Estimated glomerular filtration rate FBC Full blood count FBG Fasting blood glucose GTT Glucose tolerance test HbA1c Glycosylated haemoglobin HDL High density lipoprotein IDF International Diabetes Federation IGT Impaired glucose tolerance test IM Intramuscularly IMAI Integrated management of adult and adolescent illness IV Intravenously K Potassium LDL Low density lipoprotein Max Maximum MI Myocardial infarction NICE National Institute of Clinical Excellence NGO Non governmental organization OD Once a day OGTT Oral glucose tolerance test QDS Four times a day RBG Random blood glucose TB Tuberculosis TDS Three times a day TIA Transient ischaemic attack WHO World Health Organization Yrs Years



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