Role of Nursing in the Continuum of Role of Nursing in the Continuum of Inpatient Diabetes CareInpatient Diabetes Care

Role of Nursing in the Continuum of Role of Nursing in the Continuum of Inpatient Diabetes CareInpatient Diabetes Care

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OverviewOverview

• Hyperglycemia in the hospital settingHyperglycemia in the hospital setting– CommonCommon– CostlyCostly– Associated with poor clinical outcomes Associated with poor clinical outcomes

• Glycemic targets have been modifiedGlycemic targets have been modified– 140-180 mg/dL140-180 mg/dL

• Insulin is the treatment of choice to manage Insulin is the treatment of choice to manage hyperglycemia hyperglycemia

• Hyperglycemia management requires Hyperglycemia management requires multidisciplinary collaborationmultidisciplinary collaboration

Nursing role is critical throughout hospitalizationNursing role is critical throughout hospitalization2

Importance of Nursing Care for Importance of Nursing Care for Improving Glycemic ControlImproving Glycemic Control

• 24-hour coverage by nursing24-hour coverage by nursing• Nursing often coordinates, and is aware of, the Nursing often coordinates, and is aware of, the

multiple services required by patientmultiple services required by patient– Travel off unit, (eg, physical therapy, X-ray)Travel off unit, (eg, physical therapy, X-ray)– Amount of food eaten (carbohydrates)Amount of food eaten (carbohydrates)– Patient’s day-to-day concernsPatient’s day-to-day concerns– Order changes (by various providers)Order changes (by various providers)

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Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.

Inpatient Glycemic Control Inpatient Glycemic Control RecommendationsRecommendations

• Identify elevated blood glucose in all hospitalized Identify elevated blood glucose in all hospitalized patientspatients

• Implement structured protocols for control of blood Implement structured protocols for control of blood glucose throughout the hospitalglucose throughout the hospital– Glucose targets:Glucose targets:

• ICU: 140-180 mg/dL for most patientsICU: 140-180 mg/dL for most patients• Noncritically ill: Fasting BG <140 mg/dL; random BG <180 Noncritically ill: Fasting BG <140 mg/dL; random BG <180

mg/dLmg/dL

• Create educational programs for all hospital Create educational programs for all hospital personnel caring for people with diabetespersonnel caring for people with diabetes

• Plan for a smooth transition to outpatient care with Plan for a smooth transition to outpatient care with appropriate diabetes managementappropriate diabetes management

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TPN, total parenteral nutrition.Carter L. Oklahoma Nutrition Manual, 12th ed. Owasso, OK: Oklahoma Dietetic Association; 2006.

Factors Affecting Blood GlucoseFactors Affecting Blood GlucoseLevels in the Hospital SettingLevels in the Hospital Setting

• Increased counter-regulatory hormonesIncreased counter-regulatory hormones• Changing IV glucose ratesChanging IV glucose rates• TPN and enteral feedingsTPN and enteral feedings• Lack of physical activityLack of physical activity• Unusual timing of insulin injectionsUnusual timing of insulin injections• Use of glucocorticoidsUse of glucocorticoids• Unpredictable or inconsistent food intakeUnpredictable or inconsistent food intake• Fear of hypoglycemiaFear of hypoglycemia• Cultural acceptance of hyperglycemiaCultural acceptance of hyperglycemia

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Glucose Control DeterioratesGlucose Control DeterioratesDuring HospitalizationDuring Hospitalization

Hyperglycemic InfluencesHyperglycemic Influences

• ““Stress” hyperglycemiaStress” hyperglycemia• Concomitant therapyConcomitant therapy• Decreased physical activityDecreased physical activity• Medication omissionsMedication omissions• Medication errorsMedication errors• Fear of hypoglycemiaFear of hypoglycemia

Hypoglycemic InfluencesHypoglycemic Influences

• Decreased caloric intakeDecreased caloric intake• Gastrointestinal illnessGastrointestinal illness• Monitored complianceMonitored compliance• Medication errorsMedication errors• Altered cognitionAltered cognition

Metchick LN, et al. Am J Med. 2002;113:317-323.6

Components of Insulin TherapyComponents of Insulin Therapy

• Basal insulinBasal insulin: the amount of insulin necessary to : the amount of insulin necessary to regulate glucose levels between meals and overnightregulate glucose levels between meals and overnight– Detemir (Levemir), glargine (Lantus), NPHDetemir (Levemir), glargine (Lantus), NPH

• Nutritional insulinNutritional insulin: insulin required to cover meals, IV : insulin required to cover meals, IV dextrose, enteral nutrition, total parenteral nutrition dextrose, enteral nutrition, total parenteral nutrition (TPN), or other nutritional supplements(TPN), or other nutritional supplements– Rapid-acting: aspart (NovoLog), glulisine (Apidra), lispro Rapid-acting: aspart (NovoLog), glulisine (Apidra), lispro

(Humalog)(Humalog)– Short-acting: regular (Humulin, Novolin)Short-acting: regular (Humulin, Novolin)

• Correction insulinCorrection insulin: supplemental doses of short- or : supplemental doses of short- or rapid-acting insulin given to correct blood glucose rapid-acting insulin given to correct blood glucose elevations that occur despite use of basal and elevations that occur despite use of basal and nutritional insulinnutritional insulin– Usually administered before meals together with nutritional Usually administered before meals together with nutritional

insulininsulin7

Maintaining Physiologic InsulinMaintaining Physiologic InsulinDelivery in the HospitalDelivery in the Hospital

Basal insulin

Mealtime insulin

(bolus)

Supplemental or “stress” insulin

(correction)

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A combination of basal, nutritional (prandial), and correction (supplemental) insulin given to maintain target glucose levelsA combination of basal, nutritional (prandial), and correction (supplemental) insulin given to maintain target glucose levels

Subcutaneous Basal-Bolus InsulinSubcutaneous Basal-Bolus Insulin

• Nutritional/prandial bolus doses of rapid- or short-acting insulin Nutritional/prandial bolus doses of rapid- or short-acting insulin may be titrated based on the CHO content of the meal, may be titrated based on the CHO content of the meal, oror fixed fixed doses may be ordered if consistent CHO meal plans are useddoses may be ordered if consistent CHO meal plans are used

• Correction bolus doses of rapid- or short-acting insulin may be Correction bolus doses of rapid- or short-acting insulin may be added to the nutritional/prandial dose to correct hyperglycemiaadded to the nutritional/prandial dose to correct hyperglycemia

• Treat hypoglycemia with oral CHO or D50 IV per hypoglycemia Treat hypoglycemia with oral CHO or D50 IV per hypoglycemia guidelines or protocolguidelines or protocol

Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.

Prolonged therapy using sliding scale regular insulin is not recommended

Prolonged therapy using sliding scale regular insulin is not recommended

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Becker T, et al. Diabetes Res Clin Pract. 2007;78:392-397.

Sliding Scale Insulin Is AssociatedSliding Scale Insulin Is AssociatedWith Higher Glucose Levels and With Higher Glucose Levels and

Poorer Clinical OutcomesPoorer Clinical Outcomes• Patients receiving a sliding scale had meanPatients receiving a sliding scale had mean

in-hospital glucose values of 213 mg/dL vs in-hospital glucose values of 213 mg/dL vs 130 mg/dL (130 mg/dL (PP<0.0001)<0.0001)

• Sliding scale insulin was associated with higher Sliding scale insulin was associated with higher odds ratios of the following outcomes:odds ratios of the following outcomes:– Cardiovascular complications or deathCardiovascular complications or death

(OR=1.86; 95% CI 0.99-3.49)(OR=1.86; 95% CI 0.99-3.49)– Sepsis or ICU admissionSepsis or ICU admission

(OR=4.98; 95% CI 2.38-10.42)(OR=4.98; 95% CI 2.38-10.42)

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Insulin Time Action ProfileInsulin Time Action Profile

Insulin Onset Peak Duration

Basal

Detemir 2 hours Relatively peakless 16-24 hours

Glargine 2-4 hours Relatively peakless 20-24 hours

NPH 2-4 hours 4-10 hours 12-18 hours

Nutritional (prandial)

Rapid-acting analog(aspart, glulisine, lispro) 5-15 min 1-2 hours 4-6 hours

Regular 30-60 min 2-3 hours 6-10 hours

Hirsch I. N Engl J Med. 2005;352:174-183.Porcellati F, et al. Diabetes Care. 2007;30:2447-2552. 11

Point of Care Glucose Testing andPoint of Care Glucose Testing andInsulin Administration Insulin Administration

• Proper timing of glucose testing and insulin Proper timing of glucose testing and insulin administration can reduce the risk of administration can reduce the risk of hypoglycemia and hyperglycemiahypoglycemia and hyperglycemia

• Administer short-acting regular insulin 30 min Administer short-acting regular insulin 30 min before mealsbefore meals– Regular insulin peaks in 2-4 hoursRegular insulin peaks in 2-4 hours

• Administer rapid-acting insulin analog 15 min Administer rapid-acting insulin analog 15 min before mealsbefore meals– Rapid-acting insulin analogs peak in 60-90 minRapid-acting insulin analogs peak in 60-90 min

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CONTROLLING CONTROLLING HYPOGLYCEMIAHYPOGLYCEMIA

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What Is Hypoglycemia?What Is Hypoglycemia?

• Blood glucose <70 mg/dL Blood glucose <70 mg/dL in the hospitalized patientin the hospitalized patient

• Also referred to as “low Also referred to as “low blood sugar”blood sugar”

• Classified as mild, Classified as mild, moderate, or severemoderate, or severe

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Signs and Symptoms of HypoglycemiaSigns and Symptoms of Hypoglycemia(Blood Glucose <70 mg/dL)(Blood Glucose <70 mg/dL)

• TachycardiaTachycardia• HungerHunger• RestlessnessRestlessness• Weakness/fatigueWeakness/fatigue• DiaphoresisDiaphoresis• PallorPallor• ShakinessShakiness

• IrritabilityIrritability• AnxiousnessAnxiousness• Light-headednessLight-headedness• Change in mental Change in mental

status (eg, confusion)status (eg, confusion)• Impaired vision or Impaired vision or

dilated pupilsdilated pupils• HeadacheHeadache

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Counter-regulatory Hormones Combating Counter-regulatory Hormones Combating HypoglycemiaHypoglycemia

• Glucagon Glucagon – Produced in the alpha cells Produced in the alpha cells

of the pancreasof the pancreas

• Epinephrine and Epinephrine and norepinephrinenorepinephrine– Responsible for many of Responsible for many of

the autonomic signs and the autonomic signs and symptoms of hypoglycemiasymptoms of hypoglycemia

• Growth hormoneGrowth hormone• CortisolCortisol

• Counter-regulatory Counter-regulatory hormones increase blood hormones increase blood glucoseglucose– During stressDuring stress– In the early morning In the early morning

(circadian rhythm) (circadian rhythm)

• Patients with type 1 Patients with type 1 diabetes have less diabetes have less counter-regulatory counter-regulatory glucagon hormone glucagon hormone reserves (within 2-5 years reserves (within 2-5 years of diagnosis) than those of diagnosis) than those with type 2 diabeteswith type 2 diabetes

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HypoglycemiaHypoglycemia

• Hypoglycemia can be life-threateningHypoglycemia can be life-threatening• Common causes of hypoglycemia in the hospital Common causes of hypoglycemia in the hospital

include:include:– Too much insulin or insulin given out of sync with Too much insulin or insulin given out of sync with

meals meals – Inadequate food intake, vomitingInadequate food intake, vomiting– Continuation of oral hypoglycemic agents, with or Continuation of oral hypoglycemic agents, with or

without insulinwithout insulin– Changes in eating status (eg, NPO)Changes in eating status (eg, NPO)– Unexpected transport off unit after insulin givenUnexpected transport off unit after insulin given

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Glucose Testing and Insulin Administration

• Timing is importantTiming is important

• Proper timing of Proper timing of glucose testing and glucose testing and insulin administration insulin administration can reduce the risk of can reduce the risk of hypoglycemiahypoglycemia

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Blood Glucose Check—Too EarlyBlood Glucose Check—Too Early

• Patient requires Patient requires regular insulin regular insulin coveragecoverage

• Blood glucose Blood glucose checked at 0610checked at 0610

• Insulin is given at Insulin is given at 06200620

• Breakfast arrives at Breakfast arrives at 07400740

• Potential harm: Potential harm: hypoglycemiahypoglycemia

• Ideally regular insulin Ideally regular insulin should be givenshould be given30 min before meal30 min before meal– If necessary, regular If necessary, regular

insulin may be given insulin may be given with the mealwith the meal

• Insulin should not be Insulin should not be given given more thanmore than 30 30 min before the mealmin before the meal

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Hypoglycemia Is Serious but TreatableHypoglycemia Is Serious but Treatable

• Institute a “Hypoglycemia Order Set” or Institute a “Hypoglycemia Order Set” or “Hypoglycemia Protocol”“Hypoglycemia Protocol”

• Know the peak time of the different typesKnow the peak time of the different typesof insulin of insulin

• Remember that more activity (energy output) or Remember that more activity (energy output) or less carbohydrate (energy intake) can cause less carbohydrate (energy intake) can cause hypoglycemiahypoglycemia

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Hypoglycemia in Renal/Liver DiseaseHypoglycemia in Renal/Liver Disease

• Rising serum Rising serum creatinine can creatinine can contribute to contribute to hypoglycemiahypoglycemia

• Liver disease can Liver disease can cause a depletion of cause a depletion of glucose reserves for glucose reserves for treatment of treatment of hypoglycemiahypoglycemia

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Essential Part of Any Insulin Use: Essential Part of Any Insulin Use: A Hypoglycemia ProtocolA Hypoglycemia Protocol

• Clear definition of hypoglycemia Clear definition of hypoglycemia – BG <70 mg/dLBG <70 mg/dL

• Nursing order to treat without delayNursing order to treat without delay– Stop insulin infusion (if applicable)Stop insulin infusion (if applicable)– Oral glucose (if patient is able to take oral)Oral glucose (if patient is able to take oral)– IV dextrose or glucagon (if patient is unable to take oral)IV dextrose or glucagon (if patient is unable to take oral)– Repeat BG monitoring 15 min after treatment for Repeat BG monitoring 15 min after treatment for

hypoglycemia and repeat treatment if BG not up to targethypoglycemia and repeat treatment if BG not up to target– Directions for when and how to restart insulinDirections for when and how to restart insulin

• Document the incidentDocument the incident• Look for the cause of hypoglycemia and determine if Look for the cause of hypoglycemia and determine if

other treatment changes are neededother treatment changes are neededBG, blood glucose.Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 22

The 15-15 RuleThe 15-15 Rule

• Give 15 grams of fast-Give 15 grams of fast-acting carbohydrate acting carbohydrate and wait 15 minutesand wait 15 minutes

• Recheck blood Recheck blood glucose and then give glucose and then give another 15 grams of another 15 grams of fast-acting fast-acting carbohydrate, if carbohydrate, if necessarynecessary

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15 Grams of Carbohydrate Raises15 Grams of Carbohydrate RaisesBlood Glucose by 30-50 mg/dLBlood Glucose by 30-50 mg/dL

• 1 tube oral glucose 1 tube oral glucose gelgel

• 3-4 glucose tablets*3-4 glucose tablets*

• ½ cup juice½ cup juice

• 1 tablespoon sugar, 1 tablespoon sugar, honey, or jellyhoney, or jelly

• 8 oz milk8 oz milk

• 1 tube oral glucose 1 tube oral glucose gelgel

• 3-4 glucose tablets*3-4 glucose tablets*

• ½ cup juice½ cup juice

• 1 tablespoon sugar, 1 tablespoon sugar, honey, or jellyhoney, or jelly

• 8 oz milk8 oz milk

* Glucose tablets may contain 4 or 5 g of glucose24

Treating Hypoglycemia When the Treating Hypoglycemia When the Patient Can SwallowPatient Can Swallow

• 15-gram glucose 15-gram glucose tube or 3-4 glucose tube or 3-4 glucose tablets* tablets*

• 4 oz fruit juice4 oz fruit juice• 8 oz milk8 oz milk

* Glucose tablets may contain 4 or 5 g of glucose 25

Treatment of Hypoglycemia in an Treatment of Hypoglycemia in an Unconscious Patient Unconscious Patient

• Use an IV site to administer dextrose Use an IV site to administer dextrose

OROR• Administer IM or SC glucagonAdminister IM or SC glucagon

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HYPERGLYCEMIAHYPERGLYCEMIA

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HyperglycemiaHyperglycemia

• What is the goal for the bedside nurse?What is the goal for the bedside nurse?– Notify the physician when blood glucose levels are Notify the physician when blood glucose levels are

out of control out of control – Implement the orders and notify the physician when Implement the orders and notify the physician when

indicated to avoid hyperglycemia and hypoglycemiaindicated to avoid hyperglycemia and hypoglycemia

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Interventions for HyperglycemiaInterventions for Hyperglycemia

• Blood glucose >200 mg/dLBlood glucose >200 mg/dL– Call the physician if:Call the physician if:

• Blood glucose >200 mg/dL on admissionBlood glucose >200 mg/dL on admission• First time BG ≥200 mg/dL if not previously reportedFirst time BG ≥200 mg/dL if not previously reported• Written in the physician orders: “Call if bloodWritten in the physician orders: “Call if blood

sugar remains out of control despite therapysugar remains out of control despite therapyor per orders”or per orders”

– Administer insulin per physician’s orderAdminister insulin per physician’s order– Hydrate the patient as indicated by physician’s orderHydrate the patient as indicated by physician’s order

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Nursing Role in Good Glycemic ControlNursing Role in Good Glycemic Control

• Point of care testing (POCT) for all patientsPoint of care testing (POCT) for all patientswith diabetes and patients who present with with diabetes and patients who present with hyperglycemia on admissionhyperglycemia on admission

• Special situations that cause hyperglycemiaSpecial situations that cause hyperglycemia– SteroidsSteroids

– Immunosuppressants (eg, cyclosporin)Immunosuppressants (eg, cyclosporin)

– Atypical antipsychoticsAtypical antipsychotics

• Enteral nutrition or total parenteral nutrition (TPN)Enteral nutrition or total parenteral nutrition (TPN)

• Start POCT without an order—need guidelineStart POCT without an order—need guidelinefor care or policyfor care or policy

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Nursing Role in Good Glycemic ControlNursing Role in Good Glycemic Control

• Appropriate timing of point of care testing/insulin Appropriate timing of point of care testing/insulin administration and meal deliveryadministration and meal delivery– Document capillary blood glucose and the time Document capillary blood glucose and the time – Document insulin dose and the time givenDocument insulin dose and the time given– Document percentage of the carbohydrate eatenDocument percentage of the carbohydrate eaten

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Give Insulin as Directed—Give Insulin as Directed—However, if a Patient Does Not Eat…However, if a Patient Does Not Eat…

• Blood glucose can drop because the Blood glucose can drop because the carbohydrates predicted did not match up to carbohydrates predicted did not match up to carbohydrates ingestedcarbohydrates ingested

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How Does Infection AffectHow Does Infection AffectBlood Glucose Levels?Blood Glucose Levels?

• Increased glucocorticoids from the adrenal Increased glucocorticoids from the adrenal glands, stimulating hepatic glucose production, glands, stimulating hepatic glucose production, causing hyperglycemiacausing hyperglycemia

• Increased epinephrine and norepinephrine Increased epinephrine and norepinephrine (catecholamines), causing increased hepatic (catecholamines), causing increased hepatic glycogen breakdown into glucose, leading to glycogen breakdown into glucose, leading to hyperglycemiahyperglycemia

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How Do Surgery and Acute Illness Affect How Do Surgery and Acute Illness Affect Blood Glucose Levels?Blood Glucose Levels?

• Increased secretion of counter-regulatory Increased secretion of counter-regulatory hormones, including cortisol, catecholamines, hormones, including cortisol, catecholamines, growth hormone, and glucagongrowth hormone, and glucagon

• These hormones cause hyperglycemia by:These hormones cause hyperglycemia by:– Inhibiting glucose uptake by muscle tissueInhibiting glucose uptake by muscle tissue– Suppressing insulin release Suppressing insulin release – Increasing breakdown of glycogen by the liverIncreasing breakdown of glycogen by the liver– Increasing peripheral insulin resistanceIncreasing peripheral insulin resistance

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What Is the Impact of NPO Status onWhat Is the Impact of NPO Status onthe Patient’s Blood Glucose Levels?the Patient’s Blood Glucose Levels?

• Ideally, patients will have surgery early in the Ideally, patients will have surgery early in the morning to avoid a prolonged NPO periodmorning to avoid a prolonged NPO period

• NPO patients need regular blood glucose NPO patients need regular blood glucose monitoring (every 4-6 hours) and may need IV monitoring (every 4-6 hours) and may need IV fluidfluid

• NPO patients on oral diabetic medications with NPO patients on oral diabetic medications with long duration are at risk for hypoglycemialong duration are at risk for hypoglycemia

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NPO PatientsNPO Patients

• Management differs for type 1 and type 2Management differs for type 1 and type 2– Type 1 patients still need basal insulinType 1 patients still need basal insulin

• Transport with insulin on boardTransport with insulin on board• Advocate for early test procedures so patients Advocate for early test procedures so patients

do not miss too many mealsdo not miss too many meals• Solution: use insulin analogs for basal/bolusSolution: use insulin analogs for basal/bolus

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NPO PatientsNPO Patients

• May give half of the basal insulin dose, hold the May give half of the basal insulin dose, hold the mealtime insulin, and continue the correction mealtime insulin, and continue the correction dosedose

• Monitor BG every 6 hours and give corrective Monitor BG every 6 hours and give corrective insulin as neededinsulin as needed

• Resume the previous regimen once the patient Resume the previous regimen once the patient is eating againis eating again

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What Is the Impact of Tube FeedingsWhat Is the Impact of Tube Feedingson Blood Glucose Levels?on Blood Glucose Levels?

• Patients on tube feedings will usually receive aPatients on tube feedings will usually receive acontinuous flow of carbohydrates via their feedingcontinuous flow of carbohydrates via their feeding

• Blood glucose monitoring (usually every 4 or 6 Blood glucose monitoring (usually every 4 or 6 hours) and scheduled dose of insulin plus hours) and scheduled dose of insulin plus corrections are neededcorrections are needed

• Interruption of feeding can cause hypoglycemiaInterruption of feeding can cause hypoglycemia– IV dextrose may be needed while the feeding is offIV dextrose may be needed while the feeding is off– Notify physician for IV dextrose and adjustment ofNotify physician for IV dextrose and adjustment of

insulin orders when there is interruption or changeinsulin orders when there is interruption or changein feeding rate in feeding rate

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What Is the Impact of Total Parenteral What Is the Impact of Total Parenteral Nutrition (TPN) on Blood Glucose?Nutrition (TPN) on Blood Glucose?

• Patients on total parenteral nutrition (TPN) mayPatients on total parenteral nutrition (TPN) mayhave insulin in the TPN or may be on SC insulinhave insulin in the TPN or may be on SC insulin

• Blood glucose monitoring every 4-6 hours is Blood glucose monitoring every 4-6 hours is neededneeded

• Interruption of TPN can cause hypoglycemiaInterruption of TPN can cause hypoglycemia– Initiation of IV dextrose may be neededInitiation of IV dextrose may be needed– Notify physician for IV dextrose and adjustment of Notify physician for IV dextrose and adjustment of

insulin orders when there is interruption or change in insulin orders when there is interruption or change in TPNTPN

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Impact of MedicationsImpact of Medicationson Blood Glucose Levelson Blood Glucose Levels

• Medications used for the treatment of comorbid Medications used for the treatment of comorbid conditions can cause hyperglycemia conditions can cause hyperglycemia – Corticosteroids (ie, solumedrol, solucortef, Corticosteroids (ie, solumedrol, solucortef,

prednisone, decadron) can increase glucose prednisone, decadron) can increase glucose production by the liver and increase insulin resistanceproduction by the liver and increase insulin resistance

– Reduction or discontinuation of the steroid can cause Reduction or discontinuation of the steroid can cause hypoglycemiahypoglycemia

– Notify physician for adjustment of insulin orders when Notify physician for adjustment of insulin orders when there is a change in steroid dosethere is a change in steroid dose

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SteroidsSteroids

• Stimulate hepatic glucose production and inhibit Stimulate hepatic glucose production and inhibit peripheral glucose uptakeperipheral glucose uptake

• Dexamethasone: half-life 48 hoursDexamethasone: half-life 48 hours• AM prednisone: AM prednisone:

– Effect usually seen after mealsEffect usually seen after meals– Peak effect on glycemia: 2 pm to 8 pm Peak effect on glycemia: 2 pm to 8 pm

Leak A, et al. Clin J Oncol Nurs. 2009;13:205-210. 41

Nursing Role in Good Glycemic ControlNursing Role in Good Glycemic Control

• Appropriate timing of PCT/insulin administration Appropriate timing of PCT/insulin administration and meal deliveryand meal delivery– Document FS blood glucose and the time Document FS blood glucose and the time – Document insulin dose and the time givenDocument insulin dose and the time given– Document percentage of the carbohydrate eatenDocument percentage of the carbohydrate eaten

Do not hold insulin just because blood glucose is under good control!

Do not hold insulin just because blood glucose is under good control!

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Nursing Role in Good Glycemic ControlNursing Role in Good Glycemic Control

• Appropriate patient handoff when transferring Appropriate patient handoff when transferring patient to another area of the hospitalpatient to another area of the hospital– Meal plan orderMeal plan order– Last capillary glucose levelLast capillary glucose level– Insulin dose and last insulin givenInsulin dose and last insulin given– Patient teaching done and patient’s response Patient teaching done and patient’s response – Identified further educational needs of patient/familyIdentified further educational needs of patient/family– Transport sheetTransport sheet

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NURSING IS CRITICAL NURSING IS CRITICAL THROUGHOUT THROUGHOUT HOSPITALIZATIONHOSPITALIZATION

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Joint Commission standards mirror those of diabetes organizations with regard to patient self-managementJoint Commission standards mirror those of diabetes organizations with regard to patient self-management

The Standards: Supporting PatientThe Standards: Supporting PatientSelf-ManagementSelf-Management

• Assessing patients’ self-management capabilitiesAssessing patients’ self-management capabilities• Providing support for patients in self-management Providing support for patients in self-management

activitiesactivities• Involving patients in developing the plan of careInvolving patients in developing the plan of care• Educating patients in the theory and skills necessary Educating patients in the theory and skills necessary

to manage their disease(s)to manage their disease(s)• Recognizing and supporting self-management Recognizing and supporting self-management

effortsefforts

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Admission: Diabetes AssessmentAdmission: Diabetes Assessment

• Documentation of type, duration of diabetes, and Documentation of type, duration of diabetes, and current treatmentcurrent treatment

• Assessment of patient’s need for diabetes and Assessment of patient’s need for diabetes and nutrition educationnutrition education

• Determination of need for meter teachingDetermination of need for meter teaching• Assessment of patient’s competencyAssessment of patient’s competency

– To perform SMBGTo perform SMBG– To manage diabetes medications and/or insulinTo manage diabetes medications and/or insulin

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Health LiteracyHealth Literacy

• Not the same as literacyNot the same as literacy• More than 40% of patients with chronic illnesses are More than 40% of patients with chronic illnesses are

functionally illiteratefunctionally illiterate• Almost a quarter of all adult Americans read at or Almost a quarter of all adult Americans read at or

below a 5th-grade level, while medical information below a 5th-grade level, while medical information leaflets are typically written at a 10th-grade reading leaflets are typically written at a 10th-grade reading level or abovelevel or above

• An estimated 3 out of 4 patients discard the An estimated 3 out of 4 patients discard the medication leafletmedication leaflet

• Low health literacy skills have increased our annual Low health literacy skills have increased our annual healthcare expenditures by $73 billionhealthcare expenditures by $73 billion

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Addressing Health LiteracyAddressing Health Literacy

• Use graphics/picturesUse graphics/pictures• Use variety of mediaUse variety of media• Use “teach back” method to assess Use “teach back” method to assess

understandingunderstanding• Focus education materials on patient action and Focus education materials on patient action and

motivationmotivation• Check for patient understandingCheck for patient understanding• Implement follow-up phone calls to reinforce Implement follow-up phone calls to reinforce

instructionsinstructions

Chugh A, et al. Front Health Serv Manage. 2009;25:11-32. 48

Health NumeracyHealth Numeracy

• Difficulty adding and subtractingDifficulty adding and subtracting• Effects in diabetesEffects in diabetes

– Carbohydrate countingCarbohydrate counting– Adding correction insulin to prandial insulinAdding correction insulin to prandial insulin– Recommended example:Recommended example:

• If your blood sugar is 80 to150,If your blood sugar is 80 to150,take 10 units ____ insulintake 10 units ____ insulin

• If your blood sugar is 151 to 200,If your blood sugar is 151 to 200,take 12 units____ insulintake 12 units____ insulin

• If your blood sugar is 201 to 250,If your blood sugar is 201 to 250,take 15 units____ insulintake 15 units____ insulin

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Patient/Family EducationPatient/Family Education

• Review/evaluate Review/evaluate insulin injection insulin injection techniquetechnique

• New to insulinNew to insulin– Instruct ASAPInstruct ASAP– Give own insulinGive own insulin

as inputas input– Use handoutsUse handouts

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TRANSITION TO DISCHARGETRANSITION TO DISCHARGE

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Ensuring Good Glycemic Control in Ensuring Good Glycemic Control in Patients Being DischargedPatients Being Discharged

• Ensure patient has survival skills—ie, diabetes Ensure patient has survival skills—ie, diabetes self-management education (DSME)self-management education (DSME)– Use of personal glucose monitorUse of personal glucose monitor– Rudiments of meal plan (effect of CHO)Rudiments of meal plan (effect of CHO)– MedicationsMedications

• How and when to administerHow and when to administer• Side effectsSide effects

– Symptoms and treatment of hypo- and hyperglycemiaSymptoms and treatment of hypo- and hyperglycemia– When and whom to contact with problemsWhen and whom to contact with problems

• Be sure patient has a name and phone numberBe sure patient has a name and phone number

– Additional education/resourcesAdditional education/resources52

Connecting Inpatient Care Connecting Inpatient Care to Outpatient Supportto Outpatient Support

• Multidisciplinary team: bedside nurse, clinical Multidisciplinary team: bedside nurse, clinical pharmacist, registered dietitian, case managerpharmacist, registered dietitian, case manager

• High-risk patients identified at admissionHigh-risk patients identified at admission• Bedside nurse does assessment using Bedside nurse does assessment using

admission database form and adds 5 questions admission database form and adds 5 questions related to diabetesrelated to diabetes

• If need identified, bedside nurse contacts If need identified, bedside nurse contacts appropriate team memberappropriate team member

Pollom RK, et al. Crit Care Nurs Q. 2004;27:185-188. 53

Transition to DischargeTransition to Discharge

• Does patient have a glucose monitor for home use?Does patient have a glucose monitor for home use?– If not, call case manager/D/C planner or diabetes care center If not, call case manager/D/C planner or diabetes care center

(DCC) to arrange for one(DCC) to arrange for one

• Does patient know how to inject insulin and how to Does patient know how to inject insulin and how to prevent and treat hypoglycemia?prevent and treat hypoglycemia?

• Does patient understand his/her diabetes therapy after Does patient understand his/her diabetes therapy after discharge? discharge?

• Does patient need more diabetes education?Does patient need more diabetes education?– Refer to DCC for further educationRefer to DCC for further education

• Does patient have appropriate outpatient follow-up Does patient have appropriate outpatient follow-up appointment with primary care or specialist?appointment with primary care or specialist?

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To Enhance Nurses’ KnowledgeTo Enhance Nurses’ Knowledge

• In-services to cover all shiftsIn-services to cover all shifts• Web-based in-services/journal clubsWeb-based in-services/journal clubs

– Can be viewed at opportune timesCan be viewed at opportune times– Offer CEsOffer CEs

• Nursing championNursing champion• Diabetes “resource nurse” on each unitDiabetes “resource nurse” on each unit

– Receive extra education re diabetesReceive extra education re diabetes– Used as “rung” on clinical ladderUsed as “rung” on clinical ladder

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Intake andidentification

Admissiondatabase

Multidisciplinaryteam referrals

Focused clinicalassessment

Focused bedsideteaching/interventions

Discharge summaryand documentation

of met needs

Appropriateinpatient/outpatient

referrals andconsultations

Multidisciplinary Multidisciplinary involvement and involvement and coordination is coordination is

requiredrequired

Pollom RK, Pollom RD. Crit Care Nurse Q. 2004;27:185-188.

Connecting Inpatient Care to Outpatient Connecting Inpatient Care to Outpatient Support: Circle of Care Support: Circle of Care

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SummarySummary

• To effectively manage diabetes and nutrition in To effectively manage diabetes and nutrition in the hospital setting, it’s important to use a the hospital setting, it’s important to use a multidisciplinary team approachmultidisciplinary team approach

• Collaboration among physicians, nurses, Collaboration among physicians, nurses, pharmacists, laboratory staff, and dietary staff pharmacists, laboratory staff, and dietary staff can optimize patient care and support favorable can optimize patient care and support favorable metabolic controlmetabolic control

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