Policy For The Nursing Management of Diabetes Mellitus in the Community & Primary Care Nurses should enable people with diabetes to access an optimum standard of …
|Policy History |Document Information |
|Issue PNF Board Approval |Author: Nina Patel, Libby Dowling, |
|10 Nov 04 |Carole Bellringer, Tracey Coyne, |
| |Ingrid Clarke |
| |Review Date: |
| |Reviewer: |
| |Last edit date: |
| |File Reference: NP 10 |
Policy for Diabetes Management in the Community
including In-Patient services
Policy Statement:
Care of people with diabetes in the community must be evidence based and
provide support in an environment that facilitates self care and
independence Where carers give support, the aim is to provide information
and training in order to carry out their role, competently confidently
All care given will be compatible with the DOH Diabetes NSF guidelines
2001 which has 12 standards
Prevention of Type 2
diabetes
Identification of people with diabetes
Empowering people with Diabetes
Clinical care of adults with diabetes
Clinical care of children and young people 2
Diabetic Emergencies
Caring for people in Hospital
Diabetes and Pregnancy
Detecting complications 3
Rationale:
Diabetes is a health limiting condition, but should not be seen as a
debility, which restricts the individuals lifestyle There are 13
million people in England with diabetes 15 have Type 1 and 85 have Type
2 It is estimated that this figure will rise to 3 million by 2010, due to
the increasing number of older people and an increase in obesity in the
population Cruikshank 1997
On diagnosis 50 of Adults will already have complications
Diabetes mellitus remains a leading cause of end stage renal disease,
blindness in working aged people and non traumatic lower limb amputation
It imposes a 3 times greater cardiovascular risk reducing life expectancy
by 30 MacKinnon 1998
Criteria for Inclusion:
All Nursing staff qualified and unqualified, on permanent, temporary or
agency contracts
Expectations of the nurse by the Trust:
All Nurses should be familiar with local guidelines which relate to
both Type 1 and 2 Diabetes, and for both adults and children
Management of people with diabetes should be inclusive of health
education and promotion, monitoring and support
Prevention strategies should include advice on diet and exercise to
avoid/reduce the incidence of overweight and obesity and reduce the
risk of developing Type 2 diabetes Eg The wake and Shake scheme in
primary schools RCN Journal article Wiltshire
Being aware that ill health can affect diabetes control where
previously the person with diabetes has been stable and well
controlled
Immobility and illness can lead to the need for an increase in oral
medication or insulin
Collaborative working with the person affected with diabetes, their
GP, paediatrician and /or specialist team is essential for good
management of diabetes and maintaining a holistic approach
Nurses should enable people with diabetes to access an optimum
standard of support care, irrespective of gender, age, race,
ability, sexuality, economic status, lifestyle, culture, and religious
or political beliefs
Particular care needs to be focused towards vulnerable clients,
children and people with learning difficulties, physical difficulties
and mental health problems This group of people with diabetes may not
have adequate exercise, and unless there is effective health care
support and advice, the nutritional intake may not meet the
requirements of a well balanced diet
All nurses need to be aware that as children grow their insulin/
medication and dietary requirements change, and therefore there is a
need for much closer monitoring, especially during puberty
Routine care for people with diabetes
Diabetes is a common condition and people presenting with this disorder,
may also be subject to other non related illness Likewise patients
presenting with other complaints may also have Diabetes In either
situation it is Important to manage the diabetes correctly whether in
hospital or out in the community Poor diabetic control may contribute
adversely to the outcome of any
other condition
People with Diabetes may experience signs and symptoms relating to
complications such as peripheral vascular disease, hypertension,
cardiovascular disease or cerebrovascular disease Similarly, diabetes is
suspected when an individual presents with the above conditions Where a
diagnosis of diabetes is confirmed good glycaemic control is important in
reducing or delaying the onset of complications associated with diabetes
mellitus
Reference should also be made to professional guidelines and departments of
:
Nutrition and Dietetics
Podiatry
Ophthalmology
Dental
Management of Adults with Type 1 Diabetes in Primary Care / Community
If treated in secondary care, upon discharge, Nurses should liaise
with the specialist team and GPs and follow individualised care plan
1 Management of Adults with Type 2 Diabetes in Primary Care/Community
Nurses should all have access to the current version of the Brent PCT
NWLHT Diabetes Management Guidelines May 2003 /04
2 Management of Children with Diabetes in the community - see section 2
3 Management of Adult Diabetes within
in-patient services
1 Conduct an holistic assessment
2 Obtain information on dietary habits, changes in weight, lifestyle and
medical history
3 Ensure the patient receives a balanced diet that meets the
individuals cultural/religious belief Best practice would include
consultation with the community dietician
4 Obtain a blood glucose profile by testing blood sugar levels before
food, 2 hours after food and at bed-time
5 Assess the stability of the individuals blood glucose control by
following the patients routine at home
NB Where the patients normal practice is to monitor blood glucose, use the
Medisense monitor provided Where the patient monitors urine sugar levels
use keto-diastix
Type 2 Diabetes
Aim: Fasting blood glucose 4-6mmol/l 5-8 frail elderly
Post meal blood glucose 8-10mmol/l 10-12 frail elderly
Where possible negotiate a realistic blood glucose target
Stable condition The individuals renal threshold could affect the amount
of glucose excreted in urine, if the person with diabetes is symptomatic in
addition to testing urine for glucose ketones capillary blood testing
should
also be done
6 Test urine for glucose 2 hours after food, conduct urine tests for
ketones For diabetes control in older adults aim mainly for negative
glycosuria unless the renal threshold is low
7 Test a fasting sample and two hours after a main meal - twice a week
8 If 2 glycosuria is recorded in adults then check the capillary blood
glucose Refer the patient to the doctor
Test for ketones if Blood Sugar is over 15 or if symptomatic of
hypo/hyperglycaemia refer to the Diabetic Specialist Team
Glycosylated haemoglobin HBA1c to measure glycaemic control should
be tested 6 monthly or, undertaken during annual screening A result
of 7 or less demonstrates good glycaemic control, UKPDS 1999
Poor diabetes control or during periods of ill health
9 Refer to GP or specialist team if blood results are consistently
outside the normal ranges
10 Test blood sugars before meals 2 hours post main meals or at bed time
Type 1 Diabetes in adults
Aim: Fasting blood glucose 4-6mmol/l 5-8 frail elderly
Post meal blood glucose 8-10mmol/l 10-12 frail elderly
Negotiate where appropriate a realistic
target
Test for ketones if Blood Sugar is over 15 or if symptomatic of
hypo/hyperglycaemia
Stable condition
11 Test urine for glucose and ketones at intervals agreed with the person
with diabetes Aim for mostly negative glycosuria depending on renal
threshold
12 Test blood glucose pre-meal at intervals agreed with the person with
diabetes
Poor diabetes control or during periods of ill health
13 Test blood glucose at 4 hourly intervals using where provided, the
Medisense blood glucose meter
14 If the person is eating test blood glucose before meals, 2 hours after
a main meal and at bed-time
15 If the patient is vomiting, not eating or is having difficulty
swallowing refer them to the GP, or Diabetic Specialist team
Remember
16 Where hypoglycaemia is suspected administer sugary drinks or 3 - 4
glucose sweets
17 During periods of ill health and/or immobility insulin requirements
will be increased by 25-50
18 Short acting insulin may need to be given three or four times a day
19 Insulin should be given regularly after negative urine test and low
capillary blood
glucose reading- It may be necessary to adjust the
dose of insulin - consult the Diabetic Nurse Specialist or Doctor
Insulin must never be omitted
20 If IV insulin is being administered, never stop this but consult the
Diabetes Specialist team or the GP
Causes of Hypoglycaemia
Missed meal or snack
Unplanned physical exercise
Gastroenteritis causing poor glucose absorption
How to recognise hypoglycaemia
Hunger
Feeling faint
Sweating
Drowsiness
Pallor
Glazed eyes
Shaking
Mood changes
Lack of concentration
Fitting / convulsing
How to treat hypoglycaemia
Provide immediate fast acting sugary drink / food - eg lucozade Cola
Fanta, NB the no of mls required will vary according to the size of
the child and should be confirmed for reference with either PDSN,
paediatrician or dietician, when at the first opportunity
Alternatively, fresh fruit juice, glucose tablets, honey or jam or
hypostop may be administered
If unconscious rub sugary jam / honey or Hypostop inside the cheek
Stay with patient / child
If
unconscious place in recovery position
Call an ambulance parent / carer if under 16
Record time of event and action taken
On recovery child patient should be encouraged to eat some slower
acting starchy food such as milk and 2 biscuits Recovery should take
between 10 - 15 mins, and afterwards may feel nauseous, tired or have
a headache
Preparation for discharge from in-patient services
21 Allow the patient to monitor their urine and blood for glucose
ketonuria using the equipment/ tests they would use at home as soon as
preparations for discharge begin
22 NB Patients should be taught how to monitor their urine and blood
sugar levels before leaving hospital
23 Arrange for a carer / district nurse to administer the medication/
insulin Where a carer is responsible for administering the
medication they should receive training to monitor the patients
condition and to give the drugs safely Where a district nurse is
responsible for giving medications and monitoring the patients
condition speak with them about the treatment, frequency and type of
monitoring the patient has been using, before discharge
24 Inform the Diabetic Nurse specialist
25 Check that the follow up appointment has been made and that a contact
phone number has been given
Ensure take home prescriptions are dispensed, correct and that the patient
has the appropriate equipment prior to discharge record book, monitoring
equipment BM stix, Keto -diastix, hypostop and glucogen
Where the patient uses their own monitoring equipment at home check with
the carer that they have sufficient supplies and that the meter is in good
working order
Diagram Summarising Prevention and Management of Diabetes DOH 2001
Prevention
Diagnosis
Continuing Care
Well———————————————————————-
———————–Being
Severe Hypoglycaemia
Major Treatment change Diabetic Keto-acidosis
Major Life Event
At risk Foot
New Complication
Residential
Care
Non Diabetes related
hosp admission New Eye complication
Pregnancy New CVA
NewCHD Erectile Dysfunction
Individualised Treatment Programmes
Every Diabetic Patient should have a full health review and
assessment every 12 months as a minimum, This would include HBA1c
testing to measure glycaemic control, see page 4
Section 2
MANAGEMENT OF CHILDREN WITH DIABETES IN THE COMMUNITY
- The vast majority of children with diabetes have Type 1
- Children are all managed by a childrens diabetes team which includes
a paediatrician, paediatric diabetes nurse specialist PDSN,
paediatric dietician and child psychologist
- The diabetes team will liaise with the named health visitor / school
nurse
- The PDSN will visit the childs school to educate staff and link with
the school nurse
- Children are managed by integrated care pathways ICPs as
collaborative working practices between professionals, parents and the
child
- Children and parents
are taught how to treat hypoglycaemia,
hyperglycaemia and sick day management with the aim of self-management
of their diabetes
DIAGNOSIS
Random blood Sugar of more than 11mmol/litre
Polyuria
Polydipsia
Weight loss
1 IMMEDIATE MANAGEMENT
Same day referral to Multidisciplinary MDT paediatric team
Involve child/ Young People YP and family in making decisions
Offer home based initial management with 24 hr access to advice
from care team
2 EDUCATION
On going education with access to information/ opportunities for
discussion at clinic visits
Tailor according to maturity, culture, existing knowledge and
wishes of child / young person and family
Explain affects of alcohol, smoking and substance misuse on
glycaemic control and vascular complications
3 ONGOING CARE
Offer an integrated package of care from MDT paediatric diabetic
team with training in clinical, educational, dietetic, lifestyle,
mental health and foot care aspects of diabetes in children and
young people
4 PSYCOLOGICAL / SOCIAL
ISSUES
Emotional and behaviour problems including family conflict
Mentoring support re self management of Diabetes
Anxiety and depression
Eating disorders
Cognitive disorders
Non adherence to treatment / therapy
5 TRANSITION TO ADULT CARE
Agree protocols for transfer from paediatric to adult services
Organise age banded clinic sessions
Encourage attendance 3-4 times per year
Allow YP time to familiarise themselves with practicalities of
transition
Offer age appropriate advice on aspects of care that change with
transfer to adult services targets for short term glycaemic
control and screening for complications
6 BLOOD GLUCOSE MONITORING
Use frequent self monitoring of blood not urine glucose
Measure blood glucose more than 4x daily during intercurrent
illness in order to try to optimise glycaemic control
Rationale
Better blood glucose control is associated with fewer and delayed
microvascular complications
Optimal blood glucose control can only be established by frequent and
accurate monitoring
Clear targets of
glycaemic control are less certain in younger
children, but there is good evidence that suboptional levels of
control are associated with acute and long-term complications in all
age groups
In very young children, monitoring optimal blood glucose control must
be balanced against the potentially increased risks of severe
hypoglycaemia DCCT, 1993
Optimal blood glucose levels are 4 - 8 mmols/l before a meal and less
than 10 mmols/l after a meal NICE, 2004
Monitoring of Blood Glucose
Self monitoring of blood glucose is essential in managing childhood and
adolescent diabetes, as it
Helps to monitor immediate and daily levels of control
Detects hypoglycaemia
Assists in managing hyperglycaemia
Promotes education around blood glucose responses to insulin, food and
exercise
Timing of blood glucose monitoring
Blood glucose should be tested
At different times during the day to assess control and make changes
to diet and insulin dose as necessary
To confirm hypoglycaemia
During intercurrant illness
In association with vigorous sport/exercise
NOTE:
Children/adolescents may not wish to check their blood glucose level
at school However, school staff must be trained in recognising the signs
and symptoms of hypoglycaemia and its treatment
Procedure
Wash hands in warm water and dry thoroughly
Insert glucose test strips into monitor
Monitor turns on automatically
Prick side of finger and apply small drop of blood to testing strip
Dispose of sharps safely
Use a new lancet for each test
Ketone Monitoring
Ketones should be tested if:
Blood glucose level is 15
The child/adolescent is unwell
The child/adolescent is excessively drowsy, has an altered conscious
level or rapid breathing
NB Ketones can be tested using either urine or blood
Procedure for Urine Testing:
Obtain a sample of urine in a clean container and
Dip testing strip into urine
Or hold testing strip under stream of urine
Shake off excess
Wait 15 seconds and read result
Procedure for Blood Testing
Wash hands in warm water and dry thoroughly
Insert ketone testing strip into monitor
Monitor turns on automatically
Prick side of finger and apply small drop
of blood to testing strip
Result will be displayed in 30 seconds
Dispose of sharps safely
Use a new lancet for each test
2 HYPOGLYCAEMIA
Definition
The level of blood glucose at which physiological and neurological
dysfunction begins This level varies between individuals, but it is
generally accepted that any blood glucose level of less than 4 should be
treated as a hypo Hypos can be asymptomatic ISPAD, 2000
Grading of Severity
Mild
Child/adolescent is aware of hypoglycaemia and self tests
Moderate
Child/adolescent cannot self-treat and requires help from someone
else, but oral treatment is successful
Severe
Child/adolescent is semi-conscious, unconscious or convulsing and may
require glucagen or IV glucose
Causes
Missed/delayed meal or snack
Unplanned physical activity
Gastroenteritis causing poor glucose absorption
NOTE: Occasional mild hypoglycaemia is normal for children with Type 1
Diabetes It shows that blood glucose levels are being kept as low as
possible
TREATMENT
of children with
HYPOGLYCAEMIA
Is the child conscious
Yes
No
Give fast-acting carbohydrate
Eg Lucozade, sweets x 2-3
Lucozade 30-50mls
Accepted
Yes No
Improving after 5-10mins? Give hypostop gel IM glucagen if
trained
05mg 5yrs,1mg5yrs
Yes No Accepted
recovering after 10-15
Mins?
Give long-acting Repeat fast-acting
Carbohydrate eg Carbohydrate Yes No
Plain biscuits x2
yes review no call 999
By PDSN/
paediatrician
Follow-up with
Long acting carbohydrate
NB Please see protocol for insulin adjustment which can be undertaken only
by trained Paediatric Diabetic specialist Nurses within community
childrens team appendix 1
3 SICK DAY RULES for Children
NEVER stop taking the insulin
Test blood glucose levels at least every 4 hours
Replace meals and snacks with frequent sugary drinks eg Lucozade,
coke, sweetened fruit juice This is because fluids are absorbed
quickly from the stomach
ALSO
Drink plenty of sugar free fluids to prevent dehydration
Test urine / blood for ketones
Refer to PDSN / paediatrician if child vomits more than once, urine /
blood is positive to ketones on more than one occasion
Appendix1
PROTOCOL FOR INSULIN ADJUSTMENT
IN CHILDREN by CCNs
Subject: Protocol for insulin dose adjustment in community paediatric
patients served by Brent PCT Community Childrens Nurses Purpose
of the direction is to prevent poor blood glucose control and help
prevent long
term complications of diabetes The insulin is
prescribed by the hospital or GP
1 Clinical Situation
i Definition of clinical condition with criteria for confirmation
Type 1 and type 2 diabetes mellitus diagnosed by GP/consultant and
confirmed by consultant
Clinical details see Appendix 1
ii Definition of eligibility for inclusion
Children aged 0-18 with type1 and 2 diabetes Under the care of the
Jeffrey Kelson Centre, Central Middlesex Hospital General
Practitioner informed of shared care via referral form
iii Criteria for exclusion
Blood glucose level exceeds 10mmols or is below 4mmols after adjusting
dose by 50
iv Action to be followed for excluded patients
Immediate discussion with Paediatric or Adult Diabetes Consultant, or
Specialist Registra, Central Middlesex Hospital
v Action to be followed for patients who will not consent or adhere to
the treatment
Arrange OPA with consultant paediatrician and record in patients
notes
2 Authorisation of Staff
i Professional qualifications of authorised staff:
RSCN or RN child approved competent by
Dr Hugh Davies through
qualifications appointment to Brent PCT Community Childrens Nursing
Team, and through induction and assessment interview
iiThe lead professional for non-professional personnel N/A
References / Sources of Further Information
DOH NSF for Diabetes 2001
DOH NSF delivery strategy for Diabetes 2002
BDA /Diabetes UK wwwdiabetesorguk
RCN guide to NSF for Diabetes 2003
Current Brent PCT NWLHT diabetes management guidelines
NICE Guidelines Management of Type 1 Diabetes in Adults 2004
NICE Guidelines Management of Type 1 Diabetes in Children 2004
see tables below wwwniceorguk
Diabetes Control and Complications Trial Research Group 1993 The effect
of intensive treatment of diabetes on the development and progression of
long-term complications in insulin-dependent diabetes mellitus New England
Journal of Medicine 329: 977-986
International Society for Paediatric and adolescent diabetes 2000
Consensus Guidelines Medical Forum International: Netherlands
NATIONAL INSTITUTE FOR CLINCAL EXCELLENCE 2004 Type 1 Diabetes in
Children and Young People
NICE: London
January 2005
This algorithm
should be interpreted, where necessary, with reference to the full
guideline
———————–
Policy For The Nursing Management of Diabetes Mellitus in the Community
Primary Care
Patient
Events
Offer an integrated package of care from a multidisciplinary paediatric
diabetes care team with training in clinical, educational, dietetic,
lifestyle, mental health and foot care aspects of diabetes in children and
young people
At every clinic visit
Measure HbA1c ensure
current level is available
for use in the clinic
Check injection sites
Measure height and
weight and calculate
body mass index
Dental and eye examinations as for other children/young people
Do not screen for blood lipids or neurological function
Consider juvenile cataracts, necrobiosis lipoidica and Addisons disease at
clinic visits
Intercurrent illness
Offer guidance - often known as
sick day rules
Offer blood/urine ketone testing
strips
Communication between
organisations
Inform children/young people and families about diabetes support groups
Regular liaison between diabetes care teams and school staff
Surgery
Only in centres with facilities for care of children/young people with
diabetes
Agree protocol for safe management
Once a year
Check for retinopathy,
microalbuminuria and
blood pressure from
12 years
Screen for thyroid
disease
Review foot care
Every 3 years
Screen for coeliac
disease
Transition to adult care
Agree protocols for transfer from paediatric to adult services
Organise age-banded clinics and joint clinics with adult services
Encourage attendance 3 or 4 times/year
Allow time for young people to familiarise themselves with the
practicalities of
transition
Timing depends on physical development, emotional maturity, stability of
health,
other life changes and local circumstances
Offer advice on aspects of care that change with transfer to adult
services
targets for short-term glycaemic control and screening for complications
Key: CSII, continuous subcutaneous insulin infusion; HbA1c, glycated
haemoglobin; MDI, multiple daily injection
Hypoglycaemia
Reduce risk by having rapid access to
carbohydrate and blood glucose
monitoring
equipment
Wear or carry type 1 diabetes identification
Offer glucagon and educate carers on emergency use
Mild to moderate hypoglycaemia aware and responds to symptoms:
Immediately consume rapidly absorbed simple carbohydrate
As symptoms improve or normoglycaemia is restored consume complex long-
acting
carbohydrate
Recheck blood glucose within 15 minutes
Severe hypoglycaemia unable to respond, semi-conscious/unconscious and
requires
assistance:
Use 10 intravenous glucose if in a hospital setting
Use intramuscular glucagon or concentrated oral glucose solution outside
hospital or
when intravenous access not practical
As symptoms improve or normoglycaemia is restored consume complex long-
acting
carbohydrate if sufficiently awake
Repeat blood glucose measurements to check if further glucose is needed
Seek medical assistance if child/young person fails to respond or
symptoms persist for more than 10 minutes
Ongoing care
Complications
Diabetic ketoacidosis
Follow British Society for Paediatric Endocrinology and Diabetes
guidelines
see page 99
Initial management
in a high-dependency unit or bed on a childrens ward
Manage in a paediatric intensive care unit if deteriorating
consciousness, suspected
cerebral oedema, inappropriate response to treatment or age less than 2
years
Children who are clinically well but with hyperglycaemia, blood pH less
than 73 and
less than 5 dehydrated may respond to oral rehydration, frequent
subcutaneous
insulin injections and blood glucose monitoring
Psychological/social issues
Complications:
Emotional and behavioural
problems including family
conflict
Anxiety and depression
Eating disorders
Cognitive disorders
Behavioural and conduct disorders
Non-adherence to therapy
Psychosocial support:
Offer timely and ongoing access to mental
health professionals
Offer structured behavioural intervention
strategies and support strategies for reducing
diabetes-related family conflict
Offer young people mentoring and selfmonitoring
of blood glucose levels supported by
problem solving
Hypoglycaemia
Reduce risk by having rapid access to carbohydrate and blood glucose
monitoring
equipment
Wear or carry type 1 diabetes identification
Offer glucagon and educate carers on emergency use
Mild to moderate
hypoglycaemia aware and responds to symptoms:
Immediately consume rapidly absorbed simple carbohydrate
As symptoms improve or normoglycaemia is restored consume complex long-
acting
carbohydrate
Recheck blood glucose within 15 minutes
Severe hypoglycaemia unable to respond, semi-conscious/unconscious and
requires
assistance:
Use 10 intravenous glucose if in a hospital setting
Use intramuscular glucagon or concentrated oral glucose solution outside
hospital or
when intravenous access not practical
Source:methodisthealth.com
