The scope of services for many convenient care clinics is expanding to encompass health education and chronic disease management. Glucose screening for patients not diagnosed with diabetes and hemoglobin A_1ctesting for patients diagnosed with diabetes are now offered by some - but not all - retail healthcare chains.

Although no major clinic chain provides primary diabetes management services in 2009, the nurse practitioners who staff these clinics are prepared to handle diabetes-related health complaints that fall within their site's established scope of care. Because diabetes is a chronic disease, it has an impact on many aspects of a patient's overall health. Therefore, questioning about it should be a standard part of every patient encounter.

The Basics

In a nutshell, the American Diabetes Association defines the various forms of diabetes as follows:

• Type 1 diabetes results from the body's failure to produce insulin. Between 5% and 10% of U.S. residents who are diagnosed with diabetes have the type 1 form.

• Type 2 diabetes results from insulin resistance (improper use of insulin) in combination with relative insulin deficiency. Most U.S. residents who are diagnosed with diabetes have the type 2 form.

• Gestational diabetes is insulin resistance or failure during pregnancy, but 5% to 10% of women with gestational diabetes end up being diagnosed with diabetes after their babies are born. In most cases, the disease is the type 2 form.

• Prediabetes exists when a person's blood glucose levels are higher than normal, but not high enough for a diagnosis of type 2 diabetes. These patients are at significant risk for developing diabetes, but the disease can be prevented or postponed with lifestyle management. The identification of patients with prediabetes is a realistic outcome for retail healthcare settings.

Blood Glucose Screening

Most retail healthcare clinics provide blood glucose screening using the capillary fingerstick method. This test is not diagnostic for any form of diabetes, and it serves only as an indicator of the patient's blood glucose level at that moment. The timing and contents of the patient's last meal influence the results. A high glucose level can be a sign that the patient should undergo a complete workup for diabetes.

The most accurate blood glucose results are produced when the patient is in a fasting state. Document the time and contents of the patient's last meal, whether the testing is performed after fasting or not. Document the results and the patient education provided about those results.

All abnormal blood glucose findings warrant referral to a primary care provider.

Acute Needs in Diabetes

The presentation of a patient in diabetic crisis is uncommon, but it is something NPs in retail healthcare clinics should be prepared for. Patients with severe hypoglycemia typically experience hunger, dizziness or shakiness. Patients with severe hyperglycemia typically experience nausea and exhibit deep breathing.

A patient in hyperglycemic crisis is likely to require insulin. A patient in hypoglycemic crisis requires immediate glucose intake. Typical forms include fruit juice, hard candy or glucose tablets, all of which are available in the pharmacies and drug stores where retail clinics are located.

More Typical Events

The more typical retail clinic interaction with a diabetes patient is described in this section. At the start of every patient interaction in a retail healthcare clinic, the NP collects a thorough history that includes questions about the presence of any chronic diseases, including diabetes. If a patient has diabetes, the provider documents which form of the disease is present and how it is being managed.

With this information, the primary reason for the visit can then be considered in appropriate context. These steps are common sense measures, to be sure. But the importance of understanding a person's medical history cannot be overstated. Although every retail healthcare clinic has patients who visit for minor problems every few months, the majority of patients are new to each setting and provider.

Routine blood glucose monitoring on patients who visit a clinic and have a secondary diagnosis of diabetes is not usually necessary. Most people do not want the added cost of clinic testing and use their own monitor to check blood sugars daily. However, some patients may seek the objective testing result for peace of mind or because they have not been performing self-monitoring regularly.

Every retail healthcare visit by a patient with diabetes presents an opportunity to remind him or her about the need to monitor blood glucose more closely during illness. For women who seek assessment and treatment for a possible urinary tract infection (UTI), explain that less-controlled blood glucose may underlie frequent UTIs and yeast infections. For other patients, ask questions such as "What is your plan when you have nausea, vomiting or diarrhea?" "Do you have a plan for glucose control when you have no appetite or a sore throat?"

Remind patients of the need to control diet and fluids and to adjust their medication regimen when they are ill. If a patient does not have a plan to handle diabetes during an illness, discuss ways to control nutrient intake and refer him or her to a primary care provider for advice on medication directions.

Elise Ledbetter is a family nurse practitioner in a Little Clinic setting in Atlanta.