0 - INTRODUCTION I, a student of 2nd Year / 1st Semester, School of Nursing of t he Guard, I am conducting a training of six weeks during the

period from May 14 to June 22 of the resulting year within Stage III, "Maternal Health and Obstetri cs," in part of Community Health at the Health Center of Trancoso. During this s tage I set myself to carry out a single school on the issue of diabetes, since i t is a very common scourge in our society. Another reason to encourage me to dev elop this theme was that sometimes I realize that there are many diabetics who l ack sufficient knowledge about their disease and the care it demands. The teachi ng was conducted on the premises of the Health Center of Trancoso, on June mmm, mmm the people aged between mmm years. This objective was to illustrate to what is diabetes, types of treatment, the care of their feet and clear up some questi ons. To facilitate the understanding of the issue, some posters were presented ( Appendix 1). 1 - DIABETES MELLITUS 1.1 - DEFINITION OF DIABETES MELLITUS According to Seeley Tate (1996), Diabetes Mellitus is a: "(...) Metabolic disease in which the use of carbohydrates is reduced and lipid and protein increased, caused by lack of insulin or an inability to respond to i nsulin, is characterized, in severe cases, by hyperglycemia, glycosuria, loss of water and electrolytes, ketoacidosis and coma. " In accordance with Jorge Costa (1995, p.197), diabetes is a chronic and widespre ad, which may develop in individuals with some susceptibility heredofamiliar and manifests itself in its typical form, due to weakness, weight loss or difficult y of growth, hyperglycemia, ketosis, acidosis and protein breakdown. Typically, there is a certain amount of glucose circulating in the blood resulting in food intake and the formation of glucose by the liver. Insulin is a hormone produced by special cells of the islets of Langerhans, beta cells, the pancreas that cont rols glucose levels in the blood, regulating the hepatic storage of glucose in t he form of glycogen and its eventual transformation into lipid or proto (hormone lipoglicemiante). In diabetes there may be an impairment of body respond to ins ulin and / or a decrease or absence of insulin the pancreas. 1.1.1 - Types of Diabetes In agreement with Suzanne Smeltzer and Brenda Bare (19 95, p.873), there are several types of diabetes mellitus which differ in relatio n to the cause, the disease course and treatment. The main classifications are: Type I: Insulin-Dependent Diabetes Mellitus (IDDM) In this form of diabetes, a re inadequate amounts of insulin produced by the pancreas, resulting in the need for insulin injections to control blood glucose. This type is characterized by sudden onset, usually before the age of thirty, be ing caused by environmental factors (toxins, viruses, changes in humoral immunit y, etc. ..) in genetically predisposed individuals. Type II: Diabetes Mellitus , Non Insulin-Dependent (NIDDM) Type II diabetes results from a decreased sensit ivity to insulin (insulin resistance), as well as a decrease in the amount of in sulin produced. This type of diabetes most often appears after the age of forty and obese individuals. It is initially treated by a diet, but if there is some p ersistence of high levels of glucose, the diet is supplemented with oral hypogly cemic agents. However, in some people with type II diabetes, oral agents are not able to control hyperglycemia, so it is necessary to the administration of insu lin. Other types of diabetes are found usually associated with other pathologi es. These are the cases of diabetes associated with diseases of the pancreas or endocrine, diabetes that can arise during pregnancy (Gestational Diabetes Mellit us), etc. .. 1.1.2 - Prevention Consistent with Phipps, Long and Woods (1990, p. 81), prevent ive health care to be taken in relation to Diabetes Mellitus can be primary or s econdary. Primary prevention is directed to be made to avoid obesity and sometim

es lowering the weight in order to prevent the onset of NIDDM. Secondary prevent ion aims at early detection and disease control. Screening programs can be carri ed out in health departments, clinics, hospital facilities for outpatient care, medical, industry, weight loss clinics or mobile health units offering programs screening for diabetes. However, for a screening program to succeed it is essential to monitor all positive findings. An important way to prevent diabe tes is education. The health education programs must involve people of all ages, especially people at risk (obese, elderly, people with a family history of diab etes, ...); in schools and industries. People with diabetes should have declared access to these educational practices, to support field maintenance, the social support systems, medical and nursing care, it is possible for the prevention an d early detection of complications. 1.1.3 - Clinical Manifestations According to Jorge Costa (1995, p.198), the mani festations of Diabetes Mellitus are very varied and depend on several factors in cluding: age of onset, the existence of other diseases, the rapid high sugar and duration of disease, as well as, the resulting complications. As a result of th e persistent increase in glucose there is an increased renal elimination of suga r, causing sweet urine (hence the name "diabetes mellitus"). The presence of sug ar in the urine draws water. Thus, diabetics, while urinating in large quantitie s (polyuria), lose calories, which causes them to lose weight and feel a sense o f increased hunger (polyphagia) and are dehydrated, condicionandolhes increased thirst (polydipsia). These are often the first symptoms of diabetes mellitus or chronic decompensated inaugural. Other early symptoms of diabetes mellitus can i nclude diarrhea and abdominal pain as well as an increased frequency of urinary infections or gynecological. However, especially in the presence of infections ( which are more frequent and more difficult to treat diabetics), trauma or any ph ysical or mental stress, the first manifestations may be changes in level of con sciousness, including coma, said cetoacidótico in diabetics type I and type II i n hyperosmolar. There are frequent complaints of vision such as blurred vision r esulting from the variation of sugar concentration at eye level. The forms of lo ng-term cause serious complications at ophthalmologic, neurological, renal and c ardiovascular systems. 1.1.4 - Diagnostic Evaluation In accordance with Suzanne Smeltzer and Brenda Bar e (1995, p. 877), a person is considered diabetic when, in at least two evaluati ons in fasting blood glucose value is less than 140 mg / dl , or if at any time of day, there is equal or greater than 200 mg / dl accompanied by complaints str ongly suggestive of diabetes. This value can be obtained by determination of glu cose in a drop of blood by bite or through the collection of blood from a vein. When levels of fasting glucose remain normal or near normal, the diagnosis shoul d be based on a glucose tolerance test. 1.1.5 - Processing In agreement with Dr. Andrew Duranteau (1981, p. 175), the tr eatment of Diabetes Mellitus is by general measures of behavior and specific med ication. The main goal of diabetes treatment is to try to normalize the activity of insulin and blood glucose levels, seeking to reduce the likelihood of develo ping vascular and neuropathic complications. For Jorge Costa (1995, p.200) there are five components in the treatment of diabetes, including diet, exercise, mon itoring, medication (when necessary), and education. Treatment is variable durin g the course of disease due to changes in lifestyle and physical and emotional c ondition, as well as to advances in treatment resulting from research. Therefore , the treatment of Diabetes Mellitus includes constant evaluations and modificat ions of the plan by health professionals and daily adjustments in therapy by the patient. Although the health care team to direct the treatment, the patient is facing the daily challenge of managing the details of a complex treatment regime n. Therefore, education of patients and their families is seen as an essential c omponent of diabetes treatment.

1.1.5.1 - Processing diet diet and weight control are the basis for treatment of diabetes. The nutritional diabetic patient has the following goals: 1 2 3 4 Pro vide all essential food components, obtain and maintain ideal weight; Meeting th e energy needs, prevent large diurnal variations in blood glucose levels and blo od levels get the most close to normal in a practical and safe, 5 Lower blood le vels of lipids, when elevated. For patients who require insulin to control blood levels of glucose,€is important to maintain as constant as possible the amount of calories and carbohydrates consumed in different meals. With respect to obese patients (especially those with type II diabetes), weight loss is key in treati ng diabetes and preventing the development of complications associated with path ology. For all diabetics, food planning must take into account patient preferenc es, your lifestyle, eating the usual times and its ethnic and cultural origins. For those who use insulin, there may be more flexibility in schedules and conten t of meals provided that the patient may, when necessary, to safely modify the d ose of insulin. 1.1.5.2 - Exercise Physical activity consistent and realistic is beneficial for older people with Diabetes Mellitus. The exercises are extremely important in th e conduct of diabetes, since they reduce the blood glucose by increasing glucose uptake by muscles of the body, improving insulin use. Also favor the movement, muscle tone, weight loss, decreased stress and feelings of well-being. We can al so consider that exercise alter the levels of high density lipoproteins and decr eased levels of total cholesterol and triglycerides. Patients participating in extended periods of exercise should test blood glucose before, during and after the period of exercise, and eat snacks with carbohydra tes when needed, to keep blood glucose levels. In obese people with type II diab etes, exercise and dietary addition to the conduct improves glucose metabolism a nd stress better insulin sensitivity and may decrease the need for insulin or or al hypoglycemic agents. For many patients, the walk is a safe and beneficial exe rcise. It requires no special equipment other than proper shoes. 1.1.5.3 - Monitoring of Glucose and Ketones The eighties was a time of rapid adv ances in available technology for monitoring glucose. The development of methods for self monitoring of blood glucose (AMGs) is seen as big news in the conduct of diabetics since the discovery of insulin. The AMGs enables the detection and prevention of hypoglycemia, hyperglycemia and normalization of blood glucose lev els, allowing diabetics to gain some independence. For most patients who require insulin, the test is recommended two to four times a day (usually before meals and bedtime). Compared to patients who use insulin before each meal, you must pe rform the test at least three times a day, to determine with certainty each dose of insulin. Patients without insulin, can be instructed to monitor blood glucos e levels at least two to three times per week. In general, the test is recommend ed whenever there is any suspicion of hypoglycaemia or hyperglycaemia. Glycosylated hemoglobin This is a blood test that reflects average blood glucose levels over a period of about two to three months. When blood glucose levels are high, a glucose molecule binds to hemoglobin in a RBC. The longer the blood glucose is above normal, the greater the number of gly cated hemoglobin. This complex (hemoglobin linked with glucose) is permanent and lasts throughout the life of the erythrocyte, about 120 days. Where are maintai ned blood glucose levels near normal, with only occasional highs, the overall va lue is not very high. However, if blood glucose levels are persistently high, th en the result of the tests will also be high. Verification Test for Urine Glucose Before the availability of AMGs, the test of glucosuria was the only method available for daily monitoring of diabetes. Howe ver, today he has limited use in the treatment of diabetes. The procedure involv es the application of a urine reagent strip and comparing the color of tape on t

he bottle. Test to check urine ketones The presence of ketones (or ketone) in urine indicat es that the control of type I diabetes is to deteriorate. When there are almost no available effective insulin, the body starts using fat for energy. Ketones ar e byproducts of the breakdown of lipids and accumulate in the blood and urine. C urrently, the only method for self-assessment of ketones is the urine test. 1.1.5.4 - In compliance with insulin therapy Seeley Tate (1996), insulin is secr eted by beta cells of islets of Langerhans.€It reduces blood glucose after meals , facilitating the capture and utilization of glucose by muscle, liver cells and fats. During periods of fasting, it inhibits the breakdown of glucose, protein a nd fat storage. In type I diabetes, the body does not produce enough insulin. Th us, it has to be administered indefinitely. In type II diabetes, insulin may be necessary for the long term to control glucose levels if diet and oral hypoglyce mic agents have failed. Furthermore, some patients whose Type II diabetes, is us ually controlled by diet or diet and oral hypoglycemic agent, may require tempor ary insulin during illness, pregnancy, surgery, or some other stressful event. O ften, insulin injections are administered twice daily (or more) in order to cont rol the increases in glucose after meals and overnight. The administration of in sulin should be made in specific locations, and the patient often switch local a dministration. The needle should be introduced with an angle of 45 º or 90 º in adipose tissue and not muscle, being necessary to fold the tissue to enter the n eedle. Figure 1 - Locations of insulin Source: Phipps, Long and Woods (1990, p. 108) Complications of insulin According to Suzanne Smeltzer and Brenda Bare (1995, p. 890), insulin may cause: Allergic-local: it is characterized by the appearance of redness, swelling, tenderness and induration of local administration, or a ri ng two to four inches. This reaction comes about one or two hours after the injecti on. The reaction usually occurs during the benign stages of therapy and may disa ppear with continued administration of insulin. Systemic-allergic reactions: rea ctions are very rare. Initially occurs in the skin an immediate local reaction t hat gradually spreads in generalized urticaria. Faced with this situation, treat ment is desensitization with small doses of insulin given in gradually increasin g amounts. These reactions are occasionally associated with generalized edema or anaphylaxis. Lipodystrophy-insulin: refers to a localized disorder of fat metab olism, whether in the form of lipoatrophy or lipoipertrofia, which occurs at the place of insulin. 1.1.5.5 - The Oral hypoglycemic agents Oral hypoglycemic agents may be effective for patients with type II diabetes, since they can not be treated with an adequ ate diet. The oral hypoglycemic agents available are the sulfoniluérias. They pr esent as a secondary effect directly stimulating the pancreas functional so that they become effective agents. These agents may not be used in the treatment of patients with type I diabetes and are prone to ketoacidosis. It is important tha t patients understand that oral agents are prescribed in addition (not replaceme nt) to other treatment modalities, such as diet and exercise. Oral hypoglycemic drugs may be temporarily abandoned in favor of insulin when patients develop hyp erglycemia due to infection, trauma or surgery. If, over time, the values of glu cose in the blood of patients fail to respond to oral hypoglycemic agents, the p atient is then treated with insulin (secondary failure). A primary failure occur s when the blood glucose level remains high a month after the initial drug. 1.2 - ACUTE COMPLICATIONS OF DIABETES According to Suzanne Smeltzer and Brenda B are (1995, p.895), there are some important acute complications in diabetes-rela

ted short-term imbalances in blood glucose, including: hypoglycemia, diabetic ke toacidosis, hyperosmolar syndrome not -ketonic hyperglycemia and early morning. Hypoglycemia (insulin reactions) the hypoglycaemia (abnormally low blood glucose ) occurs when glucose falls below 50-60 mg / dl. It can be caused by excess insu lin or oral hypoglycemic agents, poor nutrition or excessive physical activity. Hypoglycaemia can occur at any time of day or night. Usually occurs before meals , especially if meals are delayed or omitted snacks. Signs and symptoms of hypog lycemia may include: pallor, tachycardia, sweating, palpitations, weakness, irri tability, headache, seizures, blurred vision, coma, etc. .. Diabetic Ketoacidosis Diabetic ketoacidosis is caused by the absence or inadequa te amount of insulin and marked. This results in disturbances in the metabolism of carbohydrates, proteins and fats. Non-ketotic hyperosmolar syndrome The non-ketonic hyperosmolar syndrome is a con dition in which hyperglycemia and hyperosmolarity with predominant sensory chang es. At the same time, ketosis is minimal or even absent. The basic biochemical d efect is the lack of effective insulin. The patient's persistent hyperglycemia leads to osmotic diuresis, resulting in t he loss of water and electrolytes. Morning hyperglycaemia A high level of blood glucose in the morning may be due to insufficient levels of insulin (end of dawn or Somogyi effect). The dawn phenomenon is characterized by relatively normal b lood glucose until about three o'clock in the morning. About and from this time, the blood glucose levels begin to rise. The phenomenon is taken as a result of increases nocturnal secretion of growth hormone, which creates a need for insuli n in the early morning hours in patients with diabetes type I. 1.3 - COMPLICATIONS OF DIABETES IN THE LONG TERM The long term complications of diabetes, are becoming more common as more people live longer with diabetes. The y can affect almost any organ system in the body. General complications of diabe tes in the long run, according to Suzanne Smeltzer and Brenda Bare (1995, p. 907 ) are: changes macrovascular (heart disease, cerebrovascular disease, peripheral vascular diseases ,...), changes microvascular (diabetic retinopathy, neurofagi as , neuropathies ,...). 1.3.1 - Problems of the Leg and Foot in Diabetes According to Suzanne Smeltzer a nd Brenda Bare (1995, p. 907), diabetes can cause serious problems in the feet a nd legs. Between fifty to seventy-five percent of lower extremity amputations ar e performed in people with diabetes. Between fifty to seventy percent of amputat ions can be avoided if potential problems are diagnosed in time and whether pati ents are receiving appropriate treatment and follow some basic rules. The typica l sequence of development of diabetic foot ulcers begins with a soft tissue inju ry of the foot, forming a cleft between the toes, or a dry area, or forming a callus. The damage is not perceived by the patient with a foot callous. If the patient does not have the habit of inspecting your feet daily, damage or tear can be missed. The redness of the leg or grangrena can be the first signs that the patient notes indicative of problems in the feet. The t reatment of foot ulcers involves bed rest, antibiotics and debridement. Furtherm ore, the control of glucose levels, which tend to increase when infections occur , it is important to promote healing. Amputation may sometimes be necessary to p revent a subsequent infection. The guidelines on assessment and care of the feet are very important when dealing with patients who have a high risk of developin g foot infections. In a comprehensive way, patients considered at high risk have the following characteristics:-duration of diabetes for over ten years;-age ove r forty years, history of smoking, decreased peripheral-pulse;-sensitivity low;deformities or anatomical pressure areas (such as calluses and bunions)-history of foot ulcers or amputation.

1.3.1.1 - Foot Care Consistent with Suzanne Smeltzer and Bare Brenda (1995, p. 9 05) along the vascular or venous settle the tertiary prevention is essential, es pecially in terms of infection. This avoids the complications preventing designa ted under the term "diabetic foot". 1. The diabetic should inspect their feet da ily, looking for blisters, cuts, scratches, spots (especially around the nails), scales or swelling. Must have attention between the toes. If the patient has di fficulty in observing the feet, should seek the assistance of a family member. 2 . The nails should always be trimmed and eradicated without rounding the corners . 3. Before cutting the nails, you should have your feet in warm water for fifteen minutes and clean them very well. The patient should seek professional help if any nail jams or if you have difficulty cutting your nails. 4. The patient shoul d wash the feet daily with warm water and soap. The water temperature should alw ays be checked by hand or by a relative. The patient should dry and feet careful ly, especially between the toes, without rubbing the skin. 5. After drying the f eet, the patient may make a slight massage with a soft cream lubricant, around t he toes and heels. The patient should not put cream between the toes, but can ap ply talcum powder between the toes. 6.€The patient should never apply strong ant iseptics in the feet or legs, especially iodine, or solutes hypochlorite (bleach smell, for example: Solute Dakin's). 7. If any court, it should be washed with soap and disinfectant should think with an antibiotic ointment and sterile gauze . The patient should not apply adhesive to the skin of the feet or legs, since t hese can irritate skin and cause sores. 8. The patient should avoid extreme temp eratures (hot or cold). The feet and legs should be protected from sunburn or co ld. You should not use hot water bottles or radiators to warm their feet. If you get cold feet in bed, the patient should wear a pair of cotton socks or wool. 9 . You should not wear socks with rubber bands, because they can produce a tourni quet-like effect, and in turn lead to the onset of swelling in that area. The pa tient must wear socks on their size and avoid the use of socks with embroidery o r textures that can irritate the skin. The socks should be changed every day. 10 . The patient must wear shoes in their size, with soft insoles and flexible sole s, preferably with adjustable laces. The sandals, which leave the toes exposed o r heels are not advisable. Regarding the new shoes, they must be used gradually to adapt to the feet. The patient should check the inside of shoes daily, to make sure they do not con tain foreign objects. If you find that the inner lining of the shoes is torn or protrusions that can scratch, you should stop using them immediately. 11. The pa tient should never walk barefoot, to avoid cuts or wounds. 12. Tobacco should be avoided. 13. The patient should not use chemicals or blades to remove calluses or warts (carnations). If these arise, seek professional help. 14. If the patien t can not heal a single wound or if you suspect a more serious problem should co nsult a doctor. If the problem persists should seek a specialist. The special ca re of feet can prevent long-term effects of diabetes. However, vascular problems and poor circulation can progress. Without immediate surgery in some situations , may result the loss of the foot or leg. The loss of sensitivity, can cause ser ious problems if preventive measures are not implemented. The loss of sensitivit y by itself is not serious, but are the possible injuries that go unnoticed that can create problems. Periodic consultations with the foot exams are extremely i mportant for the prevention and treatment of problems caused by diabetes. 2 - CONCLUSION At the end of this teaching, little more can I add this conclusio n also noted that this was an experience that contributed greatly to my personal enrichment. My commitment to the development of this teaching was very helpful, because that allowed me to gain deeper knowledge on the subject that was addres sed. The teaching was not presented in the same way that is documented, as has b een done to people whose level of understanding and knowledge was rather limited . Thus, teaching was adapted so that the essential ideas were provided. As regar

ds the preparation and presentation of education we had no difficulties. In rela tion to the objectives that were outlined by me earlier this school, it was my d esire to reach them and I believe have done so. As a future nurse, individual ed ucation to accomplish this not only allowed me to deepen my knowledge related to diabetes, as well as understand some of the complexity of this disease and prep are myself for my future and career stages, where the daily confrontation with d iabetes will be somewhat common. 3 - BIBLIOGRAPHY COSTA, Jorge - Practical Guide to Health Lisbon: Terramar, 1995 . ISBN 972-710-121-6. DUARTE, Cristina - Education of the chronically ill. "Diab etes, Living in Balance". Lisbon. ISSN 0873-450X. No. 17 (1999), 10-11. Durantea u, André - Elementary Medical Dictionary. Lisbon: Publicações Europa-América, 19 81. FISHER, James, BARRY, and General [et al] - The World of Man. Portugal: Publ icações Europa-América, 1969. MATOS, Pedro - Cardiac complications. "Diabetes, L iving in Balance". Lisbon. ISSN 0873-450X. No. 11 (1999), 9-11. PHIPPS, LONG AND WOODS - Medical-Surgical Nursing. Lisbon: Lusodidacta, 1990. ISBN 972-95-399-0I. SMELTZER, Suzanne and BARE, Brenda - Medical-Surgical. Rio de Janeiro: Guanab ara Koogan, 1995. ISBN 85-277-0272-X. SUMMARY Leaf 0 - INTRODUCTION ............................................. .... .............................................. .......... 4 1 - DIABETES MELLITU S ................................... .......................................... ............. 5 1.1 - DEFINITION OF DIABETES MELLITUS .......................... ................... ............... 5 1.1.1 - Types of Diabetes ................ ........... .................................................. ................. .. 5 1.1.2 - Prevention ......................... .............................. .................... .................................. 6 1.1.3-Clinical Manifes tations ......... .................................................. ........... .................... 7 1.1.4 - Diagnostic Evaluation ............ .............. .................................... ........................... 8 1.1.5 - Treat ment ................. .................................................. ...... .................................. 8 1.1.5.1 - Dietary Treatment ... ........... ....................................... ...................................... 9 1.1.5.2 - Financial ...... .................................................. . ................................................. .9 1.1.5.3 - Monitoring of Glu cose and Ketones ....................................... ....................... .. 10 1.1.5.4 - Insulin ................... .................................... .............. ............................. 11 1.1.5.5 - oral hypoglycemic agen ts ............. .................................................. ....... 13 1 .2 - ACUTE COMPLICATIONS OF DIABETES .................................... ...... .......... 14 1.3 - LONG-TERM COMPLICATIONS OF DIABETES ........................ . ............ 15 1.3.1 - Problems of the Leg and Foot in Diabetes ............. ............. ................................ 15 1.3.1.1 - Foot Care ......... .................................................. ............................. February 16 - CONCLUSION ................. .................................... .............. ...................................... March 19 - BIBLIOGRAPHY .. ...... .................................................. ...................... ..................... 20 APPENDICES Appendix 1 - Posters ............................................. .. ................................................ ........... 22 INDEX OF FIGURES Figure 1 Leaf - Places of insulin ............................. ......... ........................ 12 ABBREVIATIONS Enf. Nd - Nurse P. - Page ACRONYMS AMGs - self-monitoring of blood glucose NIDDM - Diabetes Mellitus, Non Insulin-Dependent IDDM - Insulin-Dependent Diabetes Mellitus

ANNEXES Annex 1 (Poster)