When a patient is diagnosed with diabetes, urinalysis should be done to detect the presence of glucose, ketones, and protein in the urine. These tests help a physician diagnose certain diabetic complications, such as DKA and renal failure.A patient who has already been diagnosed with diabetes should periodically have urine ketone and urine protein tests to check for these complications. Routine urinalysis can be used for such monitoring, but patients typically perform the tests themselves using a kit with a dipstick or enzymatic tablet.

Urine Glucose Test

The urine glucose test, which detects the presence of glucose in the urine, is no longer used to diagnose diabetes because blood glucose tests provide more accurate results. If routine urinalysis reveals glucose in a patient’s urine, she should have a blood glucose test to confirm a diagnosis of diabetes.

The use of urine glucose tests to monitor diabetes treatment has diminished because blood glucose monitors are so convenient, inexpensive, and accurate. These monitors give the precise level of glucose in the blood, whereas urine glucose tests merely detect the presence of glucose in urine. Because glucose appears in the urine of adults with healthy kidneys only when blood glucose levels rise above 180 mg/dl, a normal result from a urine glucose test tells the patient little: She may be hypoglycemic, euglycemic, or mildly to moderately hyperglycemic.

Urine Ketone Test

The urine ketone test, which detects ketones in the urine, aids in the diagnosis of DKA. Ketones are the end products of fat metabolism, which occurs when glucose isn’t available for cell use. When blood cells use fat for energy in place of glucose, fat metabolism is incomplete, and ketones accumulate in the patient’s blood. Ketones eventually spill over into the patient’s urine and can be detected by urinalysis. Ketones usually appear in the urine when blood glucose levels are consistently above 240 mg/dl.

If your patient has Type 1 diabetes, she’s prone to develop DKA. When she experiences acute illness or stress, when her blood glucose levels are consistently above 240 mg/dl, or when she has signs or symptoms of DKA (nausea, vomiting, and abdominal pain), she should test her urine for ketones every 4 hours. A pregnant woman with diabetes should test her urine for ketones to monitor her diabetes control. If they’re present, her physician will change her treatment plan.

Urine Protein Test

The urine protein test detects the presence of protein (albumin) in the urine. Usually, small amounts of protein go undetected in routine urinalysis. When protein is detected, the cause may be renal impairment from diabetes. Or it may just be strenuous exercise, exposure to cold, or emotional stress.

When protein is detected in a patient with diabetes, urinalysis should be repeated. If the second test detects protein too, a 24-hour urine protein test should be done to determine the type of renal impairment. Protein levels of 150 mg in urine over 24 hours are normal. Levels higher than 150 mg indicate the need for further testing.

Diabetes can seriously impair kidney function and is one of the leading causes of end-stage renal disease. Even if your patient has no protein in her urine when she’s diagnosed with diabetes, encourage her to have her urine monitored periodically. All postpubertal patients who’ve had diabetes for 5 years or more and all patients with Type 2 diabetes should have their urine tested for protein once a year. inaccurate test results, send the urine sample to the laboratory immediately. If this isn’t possible, refrigerate the sample until it’s transported.

If you’re using a dipstick or enzymatic tablet to test urine, carefully follow the manufacturer’s instructions. Recheck abnormal results.

When preparing your patient for a 24-hour urine collection, tell her to save all urine in the special container provided. She should keep the container refrigerated throughout the collection period. Instruct the patient not to contaminate the urine with toilet tissue, vaginal secretions, mucus, or fecal material. She should maintain a normal fluid intake because diluted urine may cause false normal results.

Nursing Considerations

Collecting urine for urinalysis requires no preparation on the part of the patient. However, you should obtain a history of recent drug use. Many drugs can alter the results of a routine urinalysis, to prevent.

The glycosylated hemoglobin test evaluates your patient’s response to diabetes therapy. The test measures the degree to which glucose attaches to hemoglobin (a process called glycosylation). Glycosylation occurs continually during the 120-day life of a red blood cell (RBC). The higher the blood glucose level, the greater the attachment. Once glucose attaches to hemoglobin, the process is nearly irreversible, which makes the glycosylated hemoglobin test an accurate reflection of your patient’s average blood glucose level during the 4 to 8 weeks before the test.The test values are given as a percentage of the total hemoglobin within an RBC. Three he­moglobins can be measured as Ala, Alb and Alc. The hemoglobin most commonly measured is Alc because it’s normally present in the largest quantity (3% to 6% of total hemoglobin). Ala is typically 1.6%, Alb is 0.8%. The closer to normal the patient can maintain her blood glucose level over an extended period, the closer to normal her glycosylated hemoglobin will be.

Nursing considerations

If your patient uses insulin, she should have a glycosylated hemoglobin test every 3 months. For patients who don’t use insulin, the frequency of the test depends on their response to therapy, which is determined by fasting blood glucose levels.

Your patient needs no preparation before the test. If you’re collecting the specimen, perform a venipuncture and collect the blood in a 5-ml lavender-top tube. Make sure the tube fills completely. Then gently invert it several times to mix the blood and anticoagulant adequately. If hemolysis occurs, collect a new specimen.

If the glycosylated hemoglobin value is elevated but the patient reports normal blood glucose levels from her self-monitoring tests, perform a second glycosylated hemoglobin test to rule out collection or laboratory error. If the second test is consistent with the first, evaluate the patient’s self-monitoring technique and correct any errors. If the patient’s technique is correct, the problem may be that she’s reporting normal values even though her tests reveal elevated glucose levels. Try to make your patient comfortable enough to express any problems she’s encountering in trying to comply with her treatment plan, and emphasize the importance of blood glucose control in delaying the development of long-term complications.

One complication of diabetes is diabetic nephropathy. A quick and simple way to check renal function is to draw a blood sample for serum creatinine and BUN tests. These tests should be performed when the patient is diagnosed with diabetes.Although the serum creatinine and BUN tests can quickly reveal the patient’s renal function, serum creatinine is the more sensitive indicator. Many extrarenal conditions, such as dehydration, can elevate the BUN level, but serum creatinine changes little except in renal disease. A normal serum creatinine level for an adult ranges between 0.7 and 1.5 mgjdl (0.6 and 1.2 mg/dl for adults over age 65). A normal BUN level for an adult ranges between 4 and 22 mg/dl (8 and 18 mgjdl for adults over age 65). Elevations in your patient’s serum creatinine and BUN levels require further testing before a physician can make a diagnosis of diabetic nephropathy

Nursing Considerations

Test results are more accurate if your patient fasts for 8 hours beforehand; therefore, try to schedule the test for first thing in the morning, so that most of the fasting time will occur while she is sleeping. Tell her not to eat breakfast.

If your patient is taking ascorbic acid, a barbiturate, or a diuretic, her physician will probably withhold it until after the test because these drugs can raise serum creatinine levels. Note whether your patient is receiving amphotericin B, an aminoglycoside, methicillin, or chloramphenicol. Any of these nephrotoxic drugs could be the source of her renal impairment.

After drawing the blood, send the sample to the laboratory immediately. To prevent hemolysis, which can alter the test results, handle the blood sample gently.

If the BUN level is elevated but the serum creatinine level isn’t, consider possible extrarenal causes before repeating the tests. Also, keep in mind that the amount of creatinine produced in the body is related to muscle mass. Therefore, an athlete with normal renal function may have elevated levels of serum creatinine.

If your patient’s serum creatinine and BUN levels are both high, check them frequently to monitor her renal function. Abnormal renal function coupled with diabetes places your patient at increased risk for endstage renal disease and cardiovascular disease. The frequency of these tests depends on how high the patient’s serum creatinine and BUN levels are and whether she exhibits other signs.

Blood Tests

Blood tests used to diagnose diabetes include the fasting blood glucose test, the 2-hour oral glucose tolerance test, and the random blood glucose test.

The glycosylated hemoglobin test is used to monitor the effectiveness of a patient’s therapy.

Blood tests used to detect and monitor the progression of diabetic complications include a fasting lipid profile for cardiovascular disease and serum creatinine and blood urea nitrogen (BUN) tests for renal disease.

Diagnostic Tests

A physician may order diagnostic tests to diagnose diabetes, detect diabetic complications, or monitor the effectiveness of a patient’s therapy. Of course, a patient should also perform self-monitoring to check the effectiveness of her therapy.

Early detection of diabetic complications allows for early treatment, which can minimize their destructive effects. Tests that help diagnose a complication can be repeated to monitor its progress

Peripheral neuropathy, a common complication of diabetes, causes sensory loss in the arms and legs. Such sensory loss in the feet increases the patient’s risk of developing foot ulcers that could ultimately lead to amputation.Usually, sensory loss is diagnosed by an examiner touching different areas of the patient’s foot with a pin. Unfortunately, this technique isn’t reliable. An examiner may not exert the same amount of pressure on each area, and some examiners are more heavy-handed than others. In fact, the same examiner may be heavy-handed one day and have a lighter touch the next, making comparisons difficult.

Filament testing with a monofilament device alleviates these problems. The device places exactly 10 grams of force on a small area of the skin . To assess sensory loss in the feet, an examiner uses the device at 10 sites on each foot.

The test result is normal if the patient feels the filament in all 10 spots on each foot. The result is abnormal if she doesn’t feel it in one or more spots.

Filament testing can be used to monitor the progression of a patient’s sensory loss and to help in tailoring an ulcer prevention program for her.

Nursing Considerations

Have the patient lie down on the examination table and instruct her to say yes each time she feels the filament.

Have her keep her eyes closed to avoid an invalid response. After the test, develop an ulcer prevention program for your patient .

This test places exercise demands on the heart and can uncover CAD not detected with an ECG. Many patients with diabetes have additional risk factors for CAD, such as obesity, hypertension, and abnormal blood lipid levels. Thus, a physician may have a patient undergo an exercise stress test even if her ECG is normal.

A stress test can also be used to monitor the progression of CAD. A patient may require periodic stress tests, especially if new symptoms of CAD appear or new risk factors are identified.

Nursing Considerations

Review your patient’s drug history and find out from her physician which drugs should be with­held and which she should take on the day of the stress test. A physician may withhold oral antidiabetic drugs because exercise lowers blood glucose levels. If your patient uses insulin, her physician may prescribe a lower dose to avoid hypoglycemia during the test.

Instruct your patient to rest the day before the test so that she has the energy to perform it. She should also fast for at least 3 hours and avoid smoking for at least 1 hour before the test. Explain to your patient what she can expect during the test and what she should wear. This information may ease her anxiety.

Determine if your patient has autonomic neuropathy, which affects involuntary functions, such as heart rate and blood pressure. During stress testing, patients with such neuropathy may not experience chest pain even though ischemia develops. Also, the blood pressure may go very high or very low when exercising. If your patient has autonomic neuropathy, closely monitor her throughout the test. The physician may even decide that an exercise stress test is inappropriate for such a patient and substitute a dipyridamole­thallium test. With this test, dipyridamole, instead of exercise, is used to put stress on the heart. The thallium acts as a contrast agent.

A fasting blood glucose test evaluates the patient’s ability to regulate glucose levels. A blood sample is taken by venipuncture after the patient has fasted for about 8 hours. Although values may vary slightly among laboratories, a finding between 70 and 120 mgjdl is considered normal in nonpregnant adults . A physician makes a diagnosis of diabetes if the finding is 126 mgjdl or more.A fasting blood glucose test can also be used to monitor the effectiveness of the patient’s treatment. If the glucose level is consistently elevated, the patient’s prescribed regimen may need to be changed. However, an elevated fasting blood glucose level in a patient with Type 1 diabetes doesn’t always signal a need for more insulin. If the patient has the Somogyi phenomenon, less insulin may be needed. This phenomenon results from insulin ­induced nocturnal hypoglycemia, which causes counter regulatory hormones to raise blood glucose levels through internal compensatory mechanisms. To alleviate the phenomenon, the physician will decrease the patient’s insulin dosage to eliminate nocturnal hypoglycemia.

Nursing Considerations

Before the test, tell your patient that she must fast for 8 hours. Make sure she understands that during the fast she may eat nothing and drink only water. Instruct her to fast for no more than 16 hours before the test. A fast of more than 16 hours or less than 8 hours can falsely increase glucose levels.

If the patient already uses insulin or an oral antidiabetic drug, her physician will withhold it during the fast. After the test, the patient can go back to her regular medication schedule. Instruct your patient to maintain a normal activity level during the fast. Any increase in activity can lower blood glucose levels and cause a false normal result.

If your patient is hospitalized before the test and her diabetic medication hasn’t been withheld during the fast, check her during the night for hypoglycemia. If she appears restless or diaphoretic while sleeping, wake her and check her blood glucose level. Nightmares and a headache in the morning also suggest nocturnal hypoglycemia. If you detect hypoglycemia, break the fast, appropriately treat the patient, and reschedule the test. If the patient isn’t hospitalized and her diabetic medication hasn’t been withheld, have a family member check her during the night.

If you draw the blood for a fasting blood glucose test to be performed at a laboratory, send the sample immediately. If the sample is left at room temperature, blood glucose levels will decrease. If you can’t send it right away, refrigerate it.

To monitor blood glucose levels at home, a patient can perform a fasting blood glucose test, using a fingers tick and a self-monitoring meter. Explain that if the test shows hyperglycemia, she should check the calibration of her meter. If it’s correct, she should repeat the test to verify her initial results. Reassure your patient that blood glucose levels fluctuate and an infrequent elevation in the fasting blood glucose level doesn’t indicate a loss of diabetic control. Elevated levels are significant only if they persist.