Carbohydrates supply the body’s primary source of energy. The brain and red blood cells use only glucose, the building block of carbohydrates. The American Diabetes Association recommends determining your patient’s protein requirements, using the recommended dietary allowance of 0.8 g/kg of body weight for adults, before determining the desired amount of carbohydrates and fat. Also, use your patient’s treatment goals, habits, and blood glucose and lipid goals as guides.When your patient chooses which carbohydrates to consume, instruct her to focus on the glycemic value of a carbohydrate rather than on the type of carbohydrate, such as simple or complex. The glycemic index, created in 1981, provides average glycemic values of certain foods. It can help you predict the rise in blood glucose after your patient has eaten certain carbohydrates. Foods that raise blood glucose levels quickly have a high glycemic value. These include white bread, some cereals, glucose, and root vegetables, such as carrots and potatoes. Foods with a low glycemic value include nuts, legumes, dairy products, fructose, and raw fruits.

Advise your patient to use the index as a guide and to monitor her blood glucose levels after she eats certain foods. Make it clear, however, that the glycemic value of a food is not equivalent to its nutritional value. Although sucrose has a lower glycemic value than a potato, for example, it provides far less nutritional value. And inform your patient that the glycemic value of a food can rise or fall depending on many factors, including the ripeness of the food, the preparation of the food, and the other foods eaten at the same meal.

If your patient is using regular insulin, she can count grams of carbohydrates to help her make food choices. Instruct her to count the total number of grams of carbohydrate in a meal she’s planning to eat. She should then compare that number to the amount of carbohydrate recommended for that particular meal in her meal plan. If she’s consuming more than is recommended, she can increase her regular insulin dose by 1 unit for every additional 10 grams of carbohydrate. If she’s consuming fewer carbohydrates than is recommended, she can decrease her insulin by 1 unit for every 10 grams less.

Instruct your patient to count grams of carbohydrates by consulting food labels, exchange lists, and carbohydrate-counting books. Counting grams of carbohydrate allows for more accurate insulin dosing and more flexible meal scheduling. It also reduces the number of hypoglycemic and hyperglycemic episodes.

Whether your patient recently learned that she has diabetes or she has been treating herself for years, during her hospitalization you should teachor reinforce-certain essential information about hypoglycemia. Be sure you cover the following areas:

• Explore the possible causes of hypoglycemia.
• Discuss the signs and symptoms of hypoglycemia.
• Discuss how to recognize and treat hypoglycemia promptly.
• Remind her to carry a simple carbohydrate snack, such as peanut butter crackers, at all times to treat hypoglycemia.
• Explain the importance of wearing a bracelet or necklace or carrying a card that indicates she has diabetes.
• Discuss the importance of telling family and friends about her diabetes in case she has a hypoglycemic episode.
• If your patient uses insulin, recommend that she obtain a glucagon kit and teach her family and friends when and how to use it.
• Teach her to monitor her blood glucose level frequently.
• Explain the importance of a regular pattern for eating meals and administering insulin or oral antidiabetic drugs.
• Explain the need to adjust the amount of food, the timing of meals and snacks, or the times of insulin administration when she engages in strenuous physical activity.
• Explain the importance of checking with the physician before taking a new prescription or over-the-counter drug.
• Instruct her to tell her health care providers that she has diabetes and that she uses insulin or oral anti diabetic drugs, as appropriate.

When caring for a patient after a kidney and pancreas transplant, repeatedly assess the function of both organs. Assess your patient for hypovolemia and dehydration, which may damage the kidney tubules and increase the risk of thrombosis of the pancreatic vessels. Monitor the patient’s intake and out­put, vital signs, skin turgor, blood urea nitrogen (BUN) level, creatinine level, and hematocrit. Elevated BUN and creatinine levels may indicate kidney dysfunction and rejection. A steadily declining hematocrit may reflect bleeding.

For the first 24 hours after surgery, adjust I.V. fluids every hour in response to your patient’s urine and nasogastric (NG) output. If she has an indwelling urinary catheter, you can monitor urine output accurately. The catheter also decompresses the bladder, allowing the suture line within to heal. After the NG tube and urinary catheter are removed, continue to monitor your patient’s intake and output.

Monitor blood glucose levels every 30 minutes to 1 hour for the first 24 hours after surgery and administer insulin or fluids containing dextrose as necessary. A patient may require insulin for 1 to 2 days after surgery because the function of the transplanted pancreas may be delayed. She may also require insulin if she’s receiving steroid therapy.

Review your patient’s daily laboratory test results, including electrolytes, complete blood count, hemoglobin level, and serum and urine amylase measurements. Collect urine specimens for cumulative amylase determinations taken at 12-hour or 24-hour intervals. Assess insulin, glucagon, and human C peptide levels three or four times per week. Pancreas scans and ultrasound examinations may be performed on the first day after surgery, then once a week until discharge. Ultrasounds examine the function of the new organs and enable the physician to determine the size of the graft and the patency of the veins.

Check your diabetes patient’s abdominal dressing and incision for blood and urinary drainage and for signs of infection. To decrease postoperative complications, have your patient sit on the side of her bed within 24 hours of surgery. She can begin sitting in a chair and taking short walks the day after surgery. Encourage her to cough, breathe deeply, and change positions frequently.

The treatment of diabetic retinopathy depends on the extent of retinal damage and may include laser photocoagulation or vitrectomy. With laser photocoagulation, the ophthalmologist uses laser beams to seal microaneurysms stream. The vascular lens refracts and focuses images onto the retina.

The choroid, or middle coat, is made up of many arteries and veins. The retina, the innermost coat of the eyeball, is rich in neurons, including the rods and cones, which serve as visual receptors. The retina is connected to the optic nerve, which conducts visual information to the brain. The vitreous humor-a thick, gelatinous material-fills the space behind the lens. It maintains the shape of the eye­ball and placement of the retina. and thus reduce their risk of bleeding. Laser photocoagulation can also be used to control new blood vessel growth .

The ophthalmologist uses vitrectomy, a surgical procedure, to treat advanced complications of proliferative retinopathy, such as vitreous hemorrhage and tractional retinal detachment.

Vitrectomy requires the use of local or general anesthesia. To begin the procedure, the ophthalmologist makes a small incision behind the cornea. Then he removes blood and fibrous tissue from the vitreous humor and replaces them with another fluid, such as normal saline. A silicone oil or gas can be used to hold the retina in place.

Riskier than laser photocoagulation, vitrectomy can result in total vision loss. Because of this, vitrectomy is typically performed on patients with a high risk of complete vision loss - for example, those with bleeding into the vitreous humor and some vision loss that hasn’t resolved after 6 months.