Chapter 2: Introduction to Diabetes Mellitus (DM)

Diabetes mellitus (DM) is the full name for the disease most commonly called Diabetes. DM is a condition that affects millions of people and it is one of the fastest growing conditions affecting society today. People with diabetes cannot produce enough or effectively use insulin to control their blood sugar (glucose) level.

Different people view diabetes differently, depending upon their perspective.

Perspective on DM of health care professionals (nurses, physicians, dieticians)

• DM is a chronic disease – it does not go away. It requires frequent and intense management.
• DM is a metabolic deficiency resulting in hyperglycemia (high blood sugar / blood glucose).
• It is a challenge to find the right treatments to decrease / prevent complications. It is difficult to get the client to accept recommendations for diet, exercise, and medications so their DM can be successfully managed.

Perspective on DM of certified DD personnel who assist the client with DM

• It is a challenge to promote the health and safety of the client diagnosed with DM.
• Problem solving is important for ensuring the client receives appropriate treatment regardless of time or place
• Caring for a person with DM provides opportunity to become more knowledgeable about care issues and develop the skills needed to provide the care needed.
• It can be worrisome to care for an individual with DM. It can be scary to administer Glucagon or give insulin as well as be responsible for recognizing signs of complications.

Perspective on DM of the person diagnosed with DM

• Because of diabetes, I have to adopt a life style I may not want to adopt.
• DM is costly. Supplies and doctors can be expensive.
• DM is with me 24-7-365. I can control it, but I can’t cure it.
• I have to consider my DM with every decision I make.
• I can die from complications. I must always guard against complications.

What is glucose and how does the body work to maintain normal glucose levels?

Glucose is the chief fuel for the body. The source of this fuel / energy [glucose] is carbohydrates (CHOs)

Glucose is a form of sugar. Often the word sugar is used when referring to glucose levels in the blood. For example, someone may refer to their blood sugar level. In this case, blood sugar level means the same thing as blood glucose level ( glucose equals sugar). Other sources of fuel for your body include protein and fats. Glucose is the only source of fuel that produces enough energy for brain function. Glucose levels must stay within normal limits to keep the body functioning normally and to its fullest capacity.

The pancreas is the organ in the body primarily responsible for making sure blood glucose levels remain within normal limits.

• The pancreas is located below the liver and behind the stomach
• The pancreas contains cells called the Islets of Langerhans. Some of these cells:
• Secrete glucagon and other hormones that help with digestion and glucose levels
• Secrete insulin
• Blood levels of glucose are regulated by glucagon and insulin. Secretion of one stimulates the secretion of the other
• Diabetes is the result of too much glucose / sugar in the blood

How The Body Controls Glucose Levels

Your body requires fuel for energy to make all of your body systems work correctly. The primary source of energy for your body is the food you eat, specifically carbohydrates (CHOs). Carbohydrates (CHOs) break down into a type of sugar after you eat them. This sugar is called glucose, and it is the body’s main fuel. When a person eats CHOs and the body breaks these foods into sugar / glucose, the sugar / glucose begins to rise in the blood.

When your body senses a rise in the blood sugar/glucose, it sends a signal to your pancreas. In response to this signal, the pancreas makes insulin and sends it into the blood stream.

Insulin lowers the level of blood sugar by acting like a key to open up the cells in the body, to allow sugar/glucose to pass from the blood into the cells to be used for fuel and energy.

The level of sugar/glucose in the blood begins to fall as the sugar/glucose passes into the cells and is used for fuel and energy.

What happens when a person’s blood glucose is too low?

When your body is getting too low on glucose, (ie. during hard work, exercise, or between meals), a signal is sent throughout your body. This signal causes your pancreas to produce glycogen. Glycogen acts like sugar / glucose and goes into your blood stream to be used for fuel until you can eat and supply your body with CHOs. While this is happening, your brain sends the message that you are hungry so you will stop and eat.

All the while, insulin is being produced by the pancreas and is being released into the blood stream to make sure all sugar sources of fuel and energy stay in balance. Other sources of fuel for your body include fats and proteins, but these are not the body’s first choice for fuel and energy.

When your body cannot detect enough sugar sources in your blood stream, it begins to breakdown fats for fuel. This might sound good, but if the person is not careful and does not replace the sugar / glucose in the blood stream, the body uses too much fat for fuel. When this happens, there are substances left in the blood from the fat burning process. These substances are called ketones. These substances are very hard for your body to get rid of and if too many ketones accumulate in the bloodstream, a person can become very ill and it can be a real emergency.

When your body has no sugar and / or no fat to use for fuel, it will turn to its protein sources. This can also be dangerous because the protein sources in your body are your muscles, which include the heart. Breaking down muscles for fuel can also make a person very ill and be a real emergency.

Why glucose blood levels become too high when a person has DM

Hormonal regulation of glucose is lost due to insulin deficiency. Insulin is the key because insulin allows the cells to utilize glucose for fuel. When a person has DM, the pancreas can’t supply enough insulin or the cells in the body cannot use the insulin that is made by the pancreas to keep the blood sugar / glucose levels in balance.

• Insulin deficiency may be absolute. Insulin deficiency may occur because the pancreas is not producing enough insulin or none at all. This is known as absolute insulin deficiency. When the beta cells in the pancreas are absent or destroyed, no insulin can be produced.
• Insulin deficiency may be relative. Insulin deficiency may occur because even though the pancreas is producing a normal amount of insulin, the person’s body needs more or is unable to use the insulin to “unlock the cells” and allow glucose to enter the cells and be used as fuel.

When the body does not have enough insulin or cannot use the insulin made by the pancreas, blood sugar / glucose levels become too high. When blood glucose levels become too high, this is called hyperglycemia.

Why an Individual might develop Diabetes Mellitus (DM)

The exact reason why insulin production is affected in some persons is often unknown, but there are some factors which predispose an individual to insulin deficiency or no insulin production. Below are some predisposing factors for DM.

• Genetics: There may be a family history of DM or a person may be born with a condition or syndrome which is associated with DM or the development of DM.
• Viruses: The beta cells in the pancreas may have been affected by a virus which attacked and destroyed them. When beta cells are absent or destroyed, no insulin can be produced.
• Abnormal Immune Response: For some reason, a person’s body may develop antibodies against cells in the pancreas. These antibodies destroy the cells in the pancreas or attack the insulin these cells create.Gestational: During pregnancy, some women have a temporary DM which very often corrects itself after the baby is born. Sometimes, however, the diabetes does not go away.
• Medication: Certain drugs (especially certain psychotropic drugs) can affect blood glucose levels.
• Obesity: Being overweight predisposes a person to develop DM. The person who is both overweight and has high blood pressure has a significant risk for developing diabetes.

Chapter 4: The Down-side of Diabetes Mellitus (DM)

Introduction:

When blood sugar / glucose levels remain out of control, DM has the potential to cause many long-term problems. The American Association of Clinical Endocrinologists recommends an individualized treatment plan that includes:

• Exercise
• Appropriate oral medications and / or insulin
• Diet guidelines
• Self-glucose monitoring
• Appropriate oral medications and / or insulin
• HbA1c less than 7 percent **

Every 3 months a health care professional should check the person’s:

• Feet
• Blood pressure
• HbA1c **
• Body for complications of DM (physical exam)
• Height / weight

NOTE: **HbA1c measures the average amount of sugar in the blood over a 3 month period of time

Annual checks should include:

• Eye exam
• Peripheral nerve test
• Stress test (Treadmill EKG)
• A diabetes education review
• Lipid profile (cholesterol - HDL, LDL, triglycerides)
• Kidney function tests (creatinine, urine protein, microalbumin)

Complications from Diabetes include:

• Stroke
• Kidney failure
• Hypertension
• Frequent infections
• Circulatory problems
• Uncontrolled blood sugar when ill
• Elevated cholesterol
• Eye problems leading to blindness
• Nerve damage from poor circulation (diabetic neuropathy)

Discussion of Complications:

Damage to Heart and Blood Vessels

Heart disease is a major cause of death in persons with diabetes mellitus (DM).

People with DM have a tendency to develop high blood pressure (BP) and high cholesterol levels.

The risk of stroke is 2-4 times higher in persons with (DM).

Problems with circulation may affect the heart, eyes, kidneys, legs, and especially the feet.

Nerve Damage: Diabetic Neuropathy

Nerve damage may occur as a result of poor circulation.

DM can cause damage to the nerves which decreases sensation to fingers, toes, hands, and feet. This is called diabetic neuropathy.

Symptoms of neuropathy include burning pain, numbness, tingling or loss of feeling in the feet or lower legs, especially at night.

Neuropathy can cause problems with sexual function in both men and women.

Neuropathy can also cause changes in stomach and bowel function.

Decreased sensation can be a serious threat to safety and security.

• When a person has decreased sensation in a particular body part, they may not realize they have injured themselves. - For example with decreased sensation in the feet a person may not realize they have stepped on something sharp and have a cut. With decreased sensation in the hands, the person may not realize they have burned themselves on something hot.
• With no pain to warn the person of injury, an infection may develop. Because the body has developed problems circulating blood, the body is less able to fight the infection and heal the injury.
• In very serious cases, infected body parts may need to be amputated. Amputation and foot ulceration are some of the most common consequences of diabetic neuropathy.

When caring for a person with diabetic neuropathy:

• Caution the person against going barefoot.
• Review safety principles of handling sharp or hot items with the person
• Instruct the person to avoid use of hot water bottles, heating pads, or any device that heats up, unless prescribed by a healthcare professional. If used, review safety principles of these devices.

Too much sugar in the blood stream coats nerves and vessels like ice coats tree branches in an ice storm. Ice covered branches become brittle and break because they have lost their flexibility. So too, blood vessels and nerves lose their flexibility and become damaged when exposed to too much blood sugar over a period of time.

Avoiding Foot Problems in the Person With DM:

Poor circulation, nerve damage and trouble fighting infection Can cause even simple foot problems to become very serious. Here are some ways to avoid complications and keep feet healthy. These are things you can do for the person or teach them to do for themselves.

• Have the client’s doctor check his/her feet at every visit.
• Have a foot doctor (podiatrist) check the client’s feet once a year.
• Check the client’s feet daily for any redness, swelling, corns, calluses, ingrown toenails, or breaks in the skin. Look between the toes and at the bottom of the foot. Use a mirror to examine the foot if it is difficult to bend down and look closely. Report any problems to the nurse or doctor immediately.
• Wash the feet daily with warm water and a mild soap. If the client has decreased sensation in the feet, test the bath water with the elbow rather than stepping right into the water which may be too hot. Dry the feet thoroughly, using the edge of the towel to carefully dry between the toes.
• If the person complains their feet are too cold, do not use a heating pad or hot water bottle to warm the feet. A diabetic with a neuropathy cannot accurately tell the temperature of something touching their feet or hands, and can be burned very easily. The person should wear cotton socks.
• Do not soak the feet. Soaking can dry the skin and cause cracking and peeling.
• If moisturizer is required, ask the doctor or nurse which would be the best to use. Only a water-based moisturizer should be used on the feet. NEVER put moisturizer between the toes or over any cuts or breaks in the skin.
• The client should be seen by a Podiatrist on a regular basis for nail trimming and cutting.
• NEVER apply tape or band-aids on the skin of the foot.
• NEVER wear socks or stockings that are too tight around the toes or ankles. Wear cotton socks that are not so big they bunch up inside the shoe when walking.
• Caution the client to NEVER go barefoot, to ALWAYS wear shoes or slippers with hard soles.
• Look inside the shoe daily to make sure there is nothing that got inside such as a stone or that the lining of the shoe is not worn or torn and bunched up inside the shoe.
• Shoes should ALWAYS be comfortable and supportive. If shoes become uncomfortable or non-supportive, it’s time to replace them.

Eye Problems:

Diabetes can affect vision by causing blood vessels in the eye to become fragile. DM is the leading cause of new cases of blindness in adults. Eye symptoms can come on slowly and the person may not notice changes in vision until the problem is no longer treatable. It is important for the person to have a complete eye examination every year.

Kidney Problems:

The person with DM should have his / her urine checked at least once a year by a doctor to rule out kidney failure or malfunctioning.

DM can cause damage to the blood vessels of the kidneys and is the leading cause of kidney failure. Once the kidneys fail, the person will need dialysis to stay alive.

Frequent Infections:

High blood sugar levels reduce the body’s ability to fight off many kinds of infections such as skin infections, bladder infections, vaginal yeast infections, tooth and gum (periodontal) infections. Even the slightest cut or sore may be slow to heal and become easily infected. Some things you can do for the person with DM or teach the person to do are cited below.

• Use sunscreen to avoid sunburns.
• Avoid dental problems by brushing and flossing daily and seeing the dentist regularly.
• Ask a nurse or doctor about getting a flu shot annually and a pneumonia vaccination.
• Wear puncture resistant gloves when doing anything that might cause injury to the skin.
• Prevent blisters by wearing socks with shoes and gloves when sweeping the sidewalk.
• Avoid frostbite in the winter by keeping hands and feet warm and wearing a hat that covers the ears. Change shoes or gloves immediately if these get wet from snow.
• Report any sign or symptoms of infection to the nurse or doctor immediately. Signs and symptoms of infection include:
• Redness
• Oozing of yellow or green discharge
• Swelling
• An area that is red and warm or hot to the touch
• Tenderness
• Temperature of greater than 100 degrees Fahrenheit
• Take care of the skin by keeping it clean. Bathe daily or every other day with warm water and a mild soap. Use a water-based moisturizer recommended by the health care professional. Avoid lotions containing perfumes.
• Wash cuts and scrapes immediately with warm water and soap. Use antibacterial ointment if recommended by the doctor or nurse. Cover the area with a bandage. Change bandage at least daily or more frequently as needed. It should be changed if it gets wet or dirty.

Managing Sick Days to Avoid Imbalances in Blood Sugar / Glucose:

Below are general guidelines you can use when the person with DM becomes sick. The delegating nurse will provide individual specific instructions.

There should be a plan for days when a person with DM becomes ill for whatever reason. Talk with the delegating nurse to determine the best actions to take if the client becomes ill.

Because illness can cause blood glucose levels to be higher or lower than normal, it is important to include more frequent Glucometer testing in the plan.

It is recommended that the client’s urine be tested for ketones (products of the breakdown of fats when the body uses fat instead of glucose for fuel). Discuss how to perform this simple test with the nurse or doctor.

If blood sugar / glucose levels become too high, the ill person may urinate more frequently. It is necessary to replace the body’s fluids to avoid dehydration. Have the client take frequent sips of low calorie, sugar free liquids such as water, unsweetened iced tea or soda or broth. If nausea and / or vomiting prevent the client from drinking fluids, call the nurse.

Follow the client’s regular meal plan as much as possible. If the client’s appetite is decreased, have him / her eat small amounts of carbohydrates every few hours. See the list below for suggestions:

• 1 twin popsicle
• 1/4 cup sherbet
• 1/2 cup ice cream
• 6 saltine crackers
• 1/2 cup apple juice
• ½ cup cooked cereal
• 1/2 cup regular soda
• 1 cup broth with noodles or rice
• 1/2 cup regular gelatin

If nausea and / or vomiting do not permit the client to eat even these small amounts of food, contact the nurse.

It is important for the client to take all of the diabetic medications ordered by the doctor during a time of illness. The client should be careful about taking any over-the-counter (OTC) medications since these can also affect blood sugar / glucose levels.

Chapter 6: Uncontrolled Blood Glucose Levels - Hypoglycemia

Hypoglycemia may also be called low blood sugar, insulin reaction, or insulin coma. Hypoglycemia happens when the blood sugar / glucose gets too low. A low blood glucose reaction is sometimes referred to as an insulin reaction, although oral hypoglycemic medications can also cause a hypoglycemic reaction.

Blood sugar is considered to be low (hypoglycemic) when a glucometer reading is below 70. The doctor and / or the nurse will provide individual specific parameters for low and high blood glucose.

Why does hypoglycemia occur?

• Stress can cause hypoglycemia
• Illness may cause hypoglycemia
• Not eating enough food during mealtime or skipping a meal or snack
• Not pre-planning for diet or medication needs for times of exercise or increased activity

Symptoms of hypoglycemia can come on suddenly. Symptoms of hypoglycemia can be physical, mental, and / or emotional. Some individuals may experience only physical symptoms, or only mental symptoms, or only emotional symptoms. Other individuals may experience a combination of symptoms. The delegating nurse will provide you the individual specific symptoms of the client for whom you are providing care and support.

Physical Signs/Symptoms of Hypoglycemia (low blood sugar) can include:

• Nausea
• Feeling too hot / cold
• Headache
• Tremors, shakiness
• Fast pulse
• Feeling dizzy / lightheaded
• Feeling hungry
• Feeling like heart “pounding”
• Blurred vision
• Excessive sweating
• Unsteadiness
• Slurred speech
• Tingling in hands feet or face
• Unsteadiness when walking, standing up, or reaching for things

Mental Symptoms of Hypoglycemia can include:

• Inability to follow directions
• Sleepiness/drowsiness, weakness
• Difficulty concentrating, slow thinking
• Feeling that something isn’t quite right
• Confusion or being disoriented: not knowing where they are, what time it is, or not recognizing people they usually know.

Emotional Symptoms of Hypoglycemia can include:

• Irritability
• Looking frantic
• Inappropriate giggling
• Change in usual behavior
• Anger
• Feeling anxious
• Sudden crying

If the blood sugar / glucose goes extremely low, the individual may be confused, disoriented, have a seizure, and / or become unconscious and remain unconscious – in a coma. These symptoms can come on very quickly. If these symptoms occur and are left untreated, the person could die.

Treatment for Hypoglycemia

In most cases hypoglycemia is easily reversible by using the correct intervention. For each client, the delegating nurse will provide you with the individual specific parameters for low and high blood glucose; blood levels below 70 mg/dl are generally considered to be hypoglycemic (low) and need treatment immediately. For each client, the delegating nurse will provide you with individual specific instructions for how to treat a hypoglycemic reaction.

Actions to Take With an Alert Individual Experiencing Hypoglycemia

If the individual is alert, can chew and swallow and follow directions and a glucometer reading reveals a glucose level of less than 70, give the person one of the items from the list below. Each item equals about 15 grams of a fast acting (CHO) carbohydrate / sugar which should raise the blood sugar approximately 30-45 points.

• 6-8 life-saver candies
• ½ cup (4-6 ounces) of fruit juice
• 1 cup (8 ounces) of milk
• 2-3 regular candies, hard or soft
• 2 tablespoons of raisins
• 1 piece of fruit (the size of a tennis ball)
• ½ cup (4-6 ounces) of regular (not diet) soda
• ½ tube of glucose gel or instant glucose (eg. Instaglucose)
• 1 tablespoon of honey, jelly, jam, corn syrup, or pancake syrup
• 1 small tube of cake decorating gel or a small tube of cake frosting
• 3 glucose tablets (5 grams of CHO each) or 4 glucose tablets (4 grams of CHO) each).

Recheck the blood sugar 15-20 minutes after the carbohydrate (CHO) has been eaten. If the blood sugar is below 70, the person is alert, can follow instructions, chew, and swallow, repeat the CHO treatment.

Recheck the client’s blood sugar in 15-20 minutes after additional CHOs have been eaten.

If the blood sugar is still below 70, or the client is still experiencing symptoms, or the client at any time becomes sleepy or unconscious, contact emergency medical personnel (911) immediately, then call the delegating or on-call nurse. Do NOT leave the client alone.

If the client’s symptoms go away, the blood sugar is above 70, and it is close to a meal or snack time (within 30-60 minutes), have the client eat their planned meal or snack. If it is not close to snack or meal time, then have the client eat a food that will be slowly digested such as a slice of bread, a slice of cheese, six crackers, one cup of milk, or one tablespoon of peanut butter.

If Client with Hypoglycemia Becomes Less Alert / Unconscious

If at any time the client’s symptoms become worse, the client becomes less alert and is not able to follow directions or chew and swallow, becomes unconscious, has difficulty breathing, or has a seizure, DO NOT TRY TO FEED THE HIM / HER.

Call for emergency medical services immediately, and notify the delegating or on-call nurse.

If a Glucagon Emergency Kit has been prescribed for the client, the order of treatment steps is as follows:

1. Call for emergency personnel
2. Administer Glucagon
3. Call the delegating or on-call nurse

Hypoglycemia in Client with a Feeding Tube

NOTE: If the Client has a feeding tube the delegating nurse may instruct you how to administer the appropriate carbohydrate (CHO) to treat hypoglycemia.

If at any time the client is observed to be increasingly symptomatic and / or becomes less alert, loses consciousness, has difficulty breathing or has a seizure, immediately stop food and / or beverage and call for emergency medical services and the delegating nurse. Follow the individual specific instructions provided by the delegating nurse and the client’s physician.

This action is very important because prolonged hypoglycemia can result in damage to the central nervous system (brain damage).

Chapter 8: Treatment of Diabetes Mellitus (DM)

The Primary Goal of Treatment

The Primary Goal of Treatment

The primary goal of treatment is to assist the client to keep blood glucose levels as normal as possible and to be as safe and healthy as possible despite having DM. In general, treatment should:

• Provide a sense of freedom
• Have the potential to be adapted to the person’s life style
• Restore the body to as normal a state of balance as possible
• Help the person live a long and healthy life, free of complications from DM
• Provide opportunities for the person to be responsible and participate in self-care
• Assist the person to live as he / she prefers as much as possible
• Provide opportunities for choice and control

Client Goals Regarding Prescribed Treatment Should Include:

• Opportunities to be responsible and participate in self-monitoring
• Maintaining the recommended diet, exercise, and medication plan and to do this with assistance as needed
• Maintain blood glucose levels within a range that avoids complications resulting from hyperglycemia (high blood sugar levels)

Goals for Healthcare Professional Regarding Treatment:

• Provide those treatments that keep blood glucose levels in check
• Provide treatments that keep carbohydrate, fat, and protein metabolism in balance
• Whenever possible, engage the client in making decisions about his treatment options
• Help the client get assistance whenever needed or inform him / her about accessible options

Goals for DD Personnel Assisting Person with DM:

• Assist the client as needed with prescribed treatment while promoting his participation in his own care.
• Administer prescribed treatment when assigned to do so by the delegating licensed nurse.
• Report to the delegating nurse any signs and symptoms of hypo or hyperglycemia exhibited by the client and / or other issues that may be affecting the client’s health and safety.
• Maintain certification, skill, and knowledge related to assisting clients with DM to follow their prescribed treatment.

Methods of Treatment for Diabetes Mellitus

All methods of treatment should compliment one another and work in conjunction with one another. Treatment methods include:

• Diet
• Exercise
• Oral medications
• Insulin
• Education
• Prevention
• Monitoring blood glucose

DIET: One of the most difficult parts of treatment for most clients and their caregivers.

An important part of dietary treatment is to consider the client’s preferences and encourage the client to make good choices. Good meal planning includes an understanding of how different foods and the amounts eaten (portions) affect blood glucose levels. Choosing healthy foods, eating regular meals at the right times, and the activity level of the client are important for maintaining blood glucose levels in the normal range.

A doctor, nurse, or dietician should provide guidelines for meal planning and assist the client to understand the nutritional component of his / her food plan. The client will be instructed to:

• Eat a variety of foods
• Use salt in moderation
• Reduce / eliminate use of refined sugar
• Eat plenty of fruits and vegetables. CAUTION: Fruits contain natural sugars which can increase blood sugar / glucose levels if not consumed with other types of foods.
• Avoid or limit the use of alcohol because the effect of alcohol on blood glucose is difficult to predict.
• Choose a diet low in fats (especially saturated fats [animal fats] and shortenings because these fats tend to raise blood cholesterol levels and are bad for the health of your heart)

To learn how to read food labels refer to the following website: http://www.cfsan.fda.gov/~dms/foodlab.html

Education:

Both the client and caregivers need to be educated about healthy choices and the client’s prescribed treatments.

Decisions made by and for the client today can impact the client in both short-term and long-term outcomes.

Exercise:

• Important in the client’s overall well-being.
• Can affect need for glucose by the body
• Improves the effects of diet and medication
• Helps control blood pressure and cholesterol level

Prevention:

There can be many serious complications from DM such as blindness, kidney failure resulting in the need for dialysis, nervous disorders, amputations from infection and poor circulation, heart disease from high blood pressure and hardening of the arteries.

Maintaining blood sugar within normal range (70-110 or prescribed parameters) is paramount to avoiding these complications.

Oral Medications:

When diet and exercise alone are not successful in lowering blood glucose, the doctor may prescribe oral medication for the client with DM. Oral medications used to help control blood glucose levels are called hypoglycemics. There are several types of oral hypoglycemics and they help lower blood sugar / glucose levels in different ways.

Some clients may need only one type of oral hypoglycemic to lower blood sugar, others may need a combination of hypoglycemics and / or insulin as well. Hypoglycemics can only work for clients whose bodies still produce some insulin.

Things to remember when a client is taking a hypoglycemic(s):

• Know the side effects for the medication(s) you are giving the client
• Talk with the delegating nurse about situations that might require you to contact her / him
• Monitor the client’s blood sugar as prescribed by the healthcare provider
• Follow any special instructions for giving this medication. Ask the nurse, pharmacist, or doctor the following questions about the medication: 1. Should the medication be given before, with, or after meals? 2. Should the medication be taken if the client feels sick? 3. Can the medication be crushed and mixed with food? 4. What should I do if a dose is missed?

Remember, even though hypoglycemics are not insulin, they do lower blood sugar and a low blood sugar reaction can occur. Be prepared to take action should this occur. Also be alert for any signs of an allergic reaction to the hypoglycemic.

Examples of common hypoglycemics:

*If the client is changed from one type of oral hypoglycemic to another, the client MUST be monitored for any potential complications or failure to respond as expected.

Monitoring Blood Glucose:

Accurate and regular testing of blood glucose levels is important for successful diabetic management. The doctor will determine the times routine blood sugars will be tested. A doctor or nurse may determine when additional testing is needed.

Blood glucose monitoring (BGM) may be ordered to be done:

• Before breakfast (fasting blood sugar)
• Whenever a client is experiencing symptoms
• Before and / or after other meals
• Before and after exercise.
• At bedtime
• When the client is sick

There are two ways to monitor blood glucose:

• A blood test known as HbA1c done in a lab: This test is done every 3-6 months and measures the client’s average blood sugar during that time. A test result of less than 7% shows good blood glucose control
• Use of a glucometer to track blood glucose at home: Home testing allows the client to make changes in meal planning as well as accommodate for increases or decreases in activity level.

Desired Blood Glucose Readings for Persons WITHOUT DM:

• 70-110 before meals
• Less than 140 two hours after meals

Desired Blood Glucose Readings for Persons WITH DM:

• Less than 110 before meals
• Less than 140 two hours after meals
• Between 100-140 at bedtime

The doctor or delegating nurse will provide you with information regarding desired glucose levels and normal ranges for an individual as part of individual specific training. The doctor or delegating nurse will give you guidelines regarding what glucose levels are to be routinely recorded on the MAR and when blood glucose levels shall be reported to the doctor or delegating nurse.

What to Consider When Choosing A Glucose Meter (Glucometer):

• Is the meter easy to hold?
• Can the numbers be seen easily?
• How many steps are required to perform the test?
• Can the strips be easily handled?
• Can the container the strips come in be opened easily?
• Are the meter and test strips covered by medical insurance?
• Are the test strips available at a local pharmacy?
• What kind of battery is used in the meter? Is it hard to change the batt
• Are the batteries available at a local pharmacy or store?

General instructions for the use of a glucometer:

All meters come with manufacturer’s instructions. Procedures often vary from manufacturer to manufacturer. As part of your individual specific training, the delegating licensed nurse will teach you how to use the meter used by the client.

Documenting test results:

Documenting test results is a necessary step in glucose monitoring and you will need to know your organization’s policies and procedures related to documenting glucose meter tests that are:

• Completed
• Missed
• Held
• Refused

The delegating licensed nurse will provide you with information about about:

• Documentation requirements for errors in the performance of glucose meter tests.
• Those situations that would require a call to the nurse or emergency personnel

Other things to consider when performing a glucose meter test:

• Protect the test strips. Sunlight, cold, and humidity can destroy test strips. Keep test strips in the container they came in. Never use test strips that have expired.
• Learn how to code the meter. Make sure the code on the meter’s display screen matches the code on the strips you are using. If these numbers do not match, you will need to recode the meter or the test result will be incorrect.
• Ask the delegating licensed nurse how to do control checks on the meter to make sure the meter is in good working order.

Whenever possible, encourage the client to participate in the testing procedure. Talk with the delegating nurse about ways to do this.

Chapter 10 Treatment of (DM): Giving Insulin

Follow the policies and procedures of your agency for insulin administration. Below is a generic procedure that can be used.

Administering a Single Dose of Insulin

PREPARING TO ADMINISTER INSULIN:

1. Wash hands with soap and water before preparing equipment
2. Prepare the injection in a clean area where you are not easily distracted
3. If ordered, perform glucometer test
4. Gather equipment: insulin syringe, cotton ball or gauze, sharps container, gloves, insulin vial, alcohol swab, small band-aid
5. FIRST CHECK: Identify the type of insulin to be given and compare label on vial with entry on the MAR. Check for 6 rights (Dr. Ti, MD)
6. Check expiration date on vial. Do not give if expired. Discard per your agency policy.
7. Be sure insulin is clear. If cloudy or if containing particles, do not use. Call delegating nurse.
8. If you are supposed to give a cloudy insulin (ie. NPH), gently roll vial between your palms 10 times. NEVER SHAKE A VIAL OF INSULIN
9. Remove cap from insulin vial
10. Clean rubber stopper with alcohol pad or cotton ball moistened with alcohol
11. Get an insulin syringe. Remove needle cover. Push plunger back and forth to make sure it moves freely. Look at needle. Do not touch needle Make sure needle is not bent and is smooth. If bent or not smooth, remove needle, place in sharps container, and place another needle on the syringe.
12. Check MAR for amount of insulin to be given. Insulin is ordered in units.
13. Pull back on the plunger to draw the same amount of air into the syringe as the dose ordered.
14. SECOND CHECK ; Check the insulin vial again against the MAR. Check for 6 rights
15. Without disturbing the plunger, insert the needle through the rubber stopper on the vial, then push air into the vial by pushing down on the plunger.
16. Place one hand on the vial and the other on the syringe. Keeping needle in the vial, turn vial upside down.
17. Fill the syringe with the required units of insulin. Be sure the needle tip in the liquid as you pull out the insulin by pulling back on the plunger.
18. With the needle still in the vial, tap the syringe to remove any air bubbles.
19. If you withdrew too much insulin, push the plunger to put the unwanted insulin back into the vial.
20. Check the syringe again to be sure you have withdrawn the prescribed units and look for air bubbles. If you have air bubbles, you may want to push the insulin back into the vial and begin again with step #17.
21. If you have the correct insulin dose and there are no air bubbles in the syringe, pull the needle from the vial.
22. Recap the needle the way the delegating nurse taught you, using a one handed technique to avoid a needle stick. Place the capped needle on a clean surface and put on gloves. Remember, if at anytime the needle becomes contaminated, you must discard the needle and syringe and start over again from step 5.
23. THIRD CHECK: When the syringe is filled, check the insulin vial again against the MAR for correct medication and the 6 rights. If there is another staff member available, have the staff member verify the dose of insulin you have prepared to make sure it is correct. Depending on your agency’s policies and procedures you and the staff who verifies the dose of insulin may be required to document on the MAR. Discuss this with your delegating nurse.
24. Put on gloves. You are now ready to administer insulin.

INSULIN ADMINISTRATION:

PREPARING THE INJECTION SITE:

1. Choose the injection area and select a site within the area that is not swollen, red, bruised, or appears hard or puckered. Do not inject into scarred areas.
2. Clean the injection site with alcohol (swab or cotton ball / gauze dipped in alcohol). Wipe away any excess alcohol with a dry, clean gauze or cotton ball. Make sure the injection site is clean and dry before injecting.

GIVING THE INJECTION:

1. Pick up the syringe. Carefully remove the cap from the needle.
2. Hold the syringe in the hand you write with.
3. Place the thumb and forefinger of your other hand on either side of the injection site, about 2 inches apart, and gently pinch up the skin. (See picture on next page)
4. With a darting motion, quickly insert the needle into the pinched skin between your thumb and forefinger. The needle should never enter the skin straight up and down (90 degree angle). Be sure the needle has gone all the way into the pinched up skin.
5. Keeping your thumb and forefinger on the skin, slide your thumb and forefinger apart, releasing the skin and returning your fingers to their original position on either side of the injection site while still holding the syringe in place with your writing hand.
6. Slowly push down on the plunger until all the insulin has been injected.
7. While holding the syringe in place with your writing hand, use the other hand to place a dry cotton ball or gauze at the injection site where the needle went in and the syringe meets the skin. Count to 5 and then pull the needle straight out.
8. Hold the cotton ball or gauze over the injection site, applying gentle pressure while counting to
9. If you observe any bleeding, hold the cotton ball or gauze over the injection site for a few more seconds. Do NOT rub the injection site.
10. Dispose of any other contaminated materials according to infection control procedures and according to your employer’s policies and procedures.
11. Remove your gloves and wash your hands.

After the injection: DO NOT RECAP THE NEEDLE! DO NOT TOUCH THE NEEDLE! Immediately dispose of the used needle and syringe by dropping them into a puncture proof container.

This container should be labeled to identify its contents. For example, it should have a label that says “SHARPS” or “USED NEEDLES AND SYRINGES” and should be stored in a secured area until it is 75% filled and ready to throw away. Discuss with the delegating nurse what type of equipment is available for this purpose and how you are to dispose of the container once it is 75% filled.

Place the container in the trash or follow the policies and procedures of your employer for disposing of contaminated materials.

DOCUMENTATION OF INSULIN ADMINISTRATION:

1. Document on the MAR under the correct date and time. Your employer may use a special form to document insulin injection rather than the MAR. You may also be required to document the location of the injection site and the number of units you administered. Any prescribed insulin doses which are missed, held, or refused by the client, must be reported to the nurse immediately. Talk with your delegating nurse about documentation requirements.
2. Any error in the insulin injection procedure must be reported to the nurse immediately and documented according to your employer’s policies and procedures.
3. Return the insulin vial to its place of storage. Return any unused syringes and other equipment to their appropriate places.
4. Observe the client for 10-15 minutes post injection to be sure they are not having a reaction to the insulin. Follow the individual specific training in regard to how soon after the insulin injection the client should eat.
5. Some clients are prescribed more than one type of insulin and may require a combination of insulins in the same injection. There are two ways this can be done. One way is by using a premixed insulin. The other way is by mixing the two types yourself. If the client you are caring for requires this type of insulin injection, the delegating nurse will instruct you in this procedure.

How to Administer a Subcutaneous Injection:

• Clean area with alcohol
• Pinch up skin between thumb and forefinger and insert needle at 45-90 degree angle
• Release pinched up skin
• Inject insulin slowly
• Withdraw needle and press gauze over injection site

Inserting the needle at a 90 degree angle or closer to a 45 degree angle depends on the amount of adipose tissue on the person. A person who is overweight or obese has enough adipose tissue to justify inserting the needle at a 90 degree angle. Very thin individuals will need to have the needle inserted at a 45 degree angle because of the close proximity of muscle tissue.

The delegating nurse will instruct you about the angle you are to use when inserting the needle when you give a subcutaneous injection.

Subcutaneous Injection Using Side of Leg as Injection Site:

General Guidelines for Needle Sticks:

• Follow your employer’s policies and procedures.
• If stuck with a clean needle, wash the area and follow the appropriate policy
• If stuck with a contaminated needle, clean the area with soap and water and an antiseptic and follow the appropriate policy.