Professional Nurses Caring for Diabetes in the Hospital Setting

Diabetes A Chronic Disease Prevalent in the United States

Between 1980 and 2003, hospital discharges coded with a diagnosis of diabetes increased from 2.2 to 5.1 milliona 132% increase in 23 years (Manchester, 2008, p. 268). Diabetic management and patient teaching can be complex and it continues to change rapidly with advances in medicine (2008).

The Science of Caring in Nursing Practice

Developing and maintaining a range of knowledge, skills, and expertise; Promoting healthy behaviors and encompassing holism; Developing and maintaining clinical competence, technical proficiency, and interpersonal skills; Being sensitive to the needs of self and others using honest communication and empathy;

 Engaging in teaching and learning that focuses on:

patient self-care, collaboration for understanding, and consideration of internal and external factors when problem solving, Watsons Philosophy and Science of Caring in Nursing Practice (Jesse, 2010).

Your Hospital Supports Nursing Practice

A promise of caring and a commitment to service
through competence, compassion,

and
an empowered accountable workforce that embraces change in the pursuit of excellence
(Mission and Values, 2013).

 A teaching hospital with nurses working at: Satellite doctors offices; Specialty healthcare facilities; After-hours express care clinics and; Inpatient and Outpatient care services. All taking care of the complex needs of many diabetic patients.
(HealthCare, 2013)

Professional Nursing Goal

All Covenant nursing staff will apply nursing science, remain current in delivering diabetic care and education to their patients in the hospital setting. Objective All Covenant nursing staff will demonstrate proficiency in caring for diabetic patients at the completion of this online program by receiving 1 CE after passing at least 85% of the program assessment questions, and completing the program evaluation.

7 Main Concepts with Objectives

Current diabetic terminology explain the difference between Type I and Type II Diabetes. Common and latest diabetic treatments - identify a contraindication for a patient using an insulin pump in the hospital setting. Common diabetic medications describe the difference between two diabetic medications. Factors affecting diabetes - name at least three factors that can affect blood glucose levels. Dietary guidelines for diabetes relate one carbohydrate dietary guideline in meal planning. Diabetes survival skills state one recommendation for selfcare during sick days. Diabetes self-management principles recall four selfmanagement principles to teach your patient.

Current Diabetic Terminology

Type I
results from B-cell destruction, usually leading to absolute insulin deficiency
(ADA, 2012, S11).

The diagnosis at present is for life and usually occurs in childhood or in young adulthood
(CDC, 2011).

 Type II
results from a progressive insulin secretory defection, the background of insulin resistance (ADA, 2012, S11). Therefore the body does not make or use insulin well. This is the most common form of diabetes (NDEP, 2012, p. 3). Type II diabetes is now diagnosed in adults, adolescents and children. Risk factors are:
obesity, inactivity, and having a family history of Type II diabetes
(ADA, 2012; CDC, 2011).

 Gestational Diabetes -

occurs during pregnancy and

is a risk factor for both the mother and child in developing Type II diabetes in the future (NDEP, 2012, p. 3). During pregnancy the hormones produced can block the action of insulin, resulting in high blood glucose levels (Wollenburg, 2011, p. 10). It is usually diagnosed at 24-28 wks gestation and resolves after delivery
(ADA, 2012).

However, women diagnosed with gestational diabetes should be monitored and screened for elevated glucose, because they have a 3560% risk of developing Type II diabetes (NDEP, 2011, p. 1). Like other types of diabetes, the high blood glucose can adversely affect the health of the baby and mother, and therefore requires monitoring & or treatment (2011).

 Insulin Resistance
occurs when the bodies cells do not respond to the insulin even though it is present. Risk factors for insulin resistance are obesity with significant belly fat, physical inactivity, and even steroid use to name a few ( NDIC, 2012).

 Pre-diabetes
a group of individuals whose glucose levels, do not meet criteria for diabetes, yet are too high to be within normal range. (e.g., impaired fasting glucose of 100 to 125mg/dl or impaired glucose tolerance of 140 to 199 mg/dl at hours) (ADA, 2012,
p. S13).

Research supports that actuallifestyle interventions reduce the risk of developing Type II diabetes by 49%... (Marrero, Acermann, Ruggiero, Kriska,
Daly, Sweeney,Stuart, 2012; NDIC, 2012; Wollenburg, 2011 ).

 DSME Diabetes self-management education is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care The objective is to:
support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team

and to improve:
clinical outcomes, health status, and quality of life

( Brown, Childs, Funnell, Haas, Hosey, & Jensen, 2011, p. S89).

 Basal Insulin
works day and night to control blood sugar
Works between meals and during sleep long acting and Are taken once or twice at the same time every day to provide 24 hour insulin coverage
(Levemir, What is Basal Insulin, 2013; Maynard, Lee, Phillips, Fink, Renvall, 2009).

Why give Basal Insulin?

Because it tries to mimic the natural balance of insulin function in the body. Remember in people without diabetes, a steady amount of insulin is released into the blood stream day and night
(2013).

 Prandial Insulins
are rapid or short acting insulins. usually administered before meals to manage meal time glucose excursion The varied quantities of protein and fat in each meal make it challenging to actually match exogenous insulin with endogenous need The pharmokinetic profile of rapid acting insulin more closely resembles prandial endogenous insulin activity
( Medscape Nurses, Basal & Prandial Insulin Options, 2013).

 Hemoglobin A1C
glucose attaches to hemoglobin and remains there for about 120 days or the life of the cell test measures the % of total hemoglobin that has glucose attached to it for a 3 to 4 month period

Persons with a repeated A1C above 5.5 are at risk for developing diabetes
Every point above 7% puts the person at a greater risk for health complications
(NDEP, 2012; ADA, 2012).

 Correlation of A1C with Average Glucose

A1C (%) 6 7 8 9 10 Mean Plasma Glucose mg/dl 126 154 183 212 240

11
12

269
298

ADA, 2012, p. S18

Common Diabetes Management for Tighter Glycemic Control

Continuous glucose monitoring. DSME with the goal for increased patient self-management. Quarterly A1C testing and Self-glucose monitoring. Insulin pumps.

Insulin therapy and ketone testing. Medical Nutrition Therapy (MNT)

is individualized evaluation and guidance provided by a Registered Dietician for the management or prevention of diabetes.

Oral medications & Incretin hormones (oral & injectable). Regular physical activity or exercise program
(ADA, 2012; Wollenburg, 2011)

Effective Diabetes Management Requires a Caring Collaborative Team

Physician, Nurse, Family, DSME Team, Case Manager

Registered Dietician, Pharmacist, Opthalmologist

Patient with Diabetes

Podiatrist, Exercise Specialist, Social Worker

Nurse Practitioner, Physician Assistant, Mental Health Expert

(Seley, et. al., 2012; Wollenburg, 2011)

Current Diabetic Terminology Review

True or False: Persons diagnosed with Type I diabetes can grow out of it or resolve it with lifestyle changes. True False

Answer
The answer is False. Rationale: Type I diabetes results from B-cell destruction, usually leading to absolute insulin deficiency
(ADA, 2012, S11).

The diagnosis at present is for life and usually occurs in childhood or in young adulthood (CDC,
2011).

Common Diabetic Medications

Various diabetes medications work differently in order to manage blood glucose. Patients may require one or more oral medicines; oral medicine and insulin; just insulin; and or the addition of injectable or oral DDp4 inhibitors. It is important to remember thatover time, changes in the types or amount of medicines are needed to keep Hgb A1c levels on target
(ADA, n.d., p.20).

 Insulin Is a hormone that affects metabolism. Its presence allows cells to absorb the glucose present after food is digested by the body (NDIC, 2012).
Injectable and used everyday by all persons with Type 1 and some people with Type 2 or even Gestational Diabetes (ADA, n.d.).

Insulin Types
Insulin Onset Peak Duration Common Names Pointers Rapid Acting 15 min 1 hour 3-4 hours Novolog, Humolog Good for 28 days once open as loses potency. Regular 30 mins 2-3 hours 3-6 hours Regular Insulin Refrigerate good till gone or expiration date. Intermediate 2-4 hours 4-10 hours 10-16 hours NPH, Lente Refrigerate good till gone or expiration date. Long- acting 1-2 hours n/a 21-24 hours Lantus, Levemir Must be administered by themselves & be given at the same time every day.

(Wollenburg, 2011).

Types of Oral Medications

Types Biguanides Action amount of stored sugar released from liver & insulin sensitivity Helps the pancreas the output of insulin Common Names Metformin or Glucophage or Riomet (liquid) Pointers Needs to be held for renal insufficiency or if testing with contrast dyes is required (ADA, 2012) Can cause low blood sugar.

Sulfonylureas

Glyburide or Micronase, Diabeta, Glynase, Glipizide or Glucotrol or Amary.

(ADA, n. d.; Wollengburg, 2011).

Types of Oral Medications (Continued)

Type Action Common Names Pointers

Meglitinides

Helps the body release quick burst of insulin when eating

Repoglinide, or Prandin, Nateglinide or Starlix

Can cause low blood sugar.

Alpha-glucosidase inhibitors

Slows digestion of Acarbose or some carbohydrates Precose, Miglitol resulting blood or Glyset glucose after meals insulin resistance to help insulin act effectively. Rosiglitzone or Avandia, Pioglitazone or Actos Contraindicated in CHF or MI due to edema. & potential serious side effects. (ADA, n.d.; Wollenburg, 2011)

Thiazolidinediones

Incretin Medications
Try to mimic Incretin Hormones and are known as glucose-like peptide-1(GLP-1), and may be used to help manage Type 1 diabetes.
They are injectable. Help the body produce insulin and help the insulin to work better. Stop the liver from releasing too much glucose after meals. Reduce appetite. Help lower blood sugar after meals by slowing food and glucose traveling through the stomach. (e.g., Byetta or Exenatide is injected twice a day, at least six hours a part about 30 min before meals, and should not be given within an hour of antibiotics or birth control pills; Liraglutide or Vitoza is injected once at the same time every day independent of meals).

(Wollenburg, 2011, p. 42)

 Other Incretin Medications are available in an oral form and are called DDP-4 or dipeptidyl peptidase-4 inhibitors and can help some patients with Type 2 diabetes.
They work by increasing insulin after meals and by decreasing the amount of sugar the liver delivers after meals. (e.g., Sitagliptin or Januvia, & Saxaglipitin or Onglyza).
(Wollenburg, 2011, p. 42).

Common Diabetic Medications Review

You are a nurse working the evening shift in the hospital. You check the patients blood glucose level at hour of sleep as scheduled. Your patient is scheduled to receive his evening dose of Lantus insulin. Your patient is asymptomatic and has a blood glucose level of 75. Your next step is to:
A) Hold the evening dose of Lantus Insulin in order to avoid a hypoglycemic event. B) Give the Lantus insulin and tell the patient to order a cheese burger, fries, and chocolate malt for his evening snack in order to avoid a hypoglycemic event. C) Check the patients previous AM blood glucose levels and if consistently running low, notify the physician as an adjustment in insulin doses may be needed, then give the Lantus as per physician order. Make sure the patient receives their hour of sleep snack as per their meal plan and as treatment orders allow, and continue to monitor.

Answer
The answer is C. Rationale:
Lantus insulin is a basal insulin which is long acting, working day and night to control blood sugar between meals and during sleep. Giving basal insulin helps the patient with diabetes try to mimic the natural balance of insulin function in the body. Calling the physician, due to the fact that the patient has been running low AM blood sugars consistently, demonstrates caring & collaborative team work for the good of the patient . (Levemir, What is Basal Insulin, 2013; Jesse,
2010).

Factors that can Affect Diabetic Management

Increase Blood Glucose:
Other medication & treatments (e.g., Vasopressors , Prednisone & parenteral nutrition) Emotional stress or inactivity (e.g., hospitalization ) Hormonal changes (e.g., menses) Disease or physiologic stress (e.g., pancreatitis Illness without vomiting (e.g., cold or flu symptoms, or other infections

Decrease Blood Glucose:

Nausea and vomiting Alcohol (e.g., first two drinks can decrease blood glucose at first, especially if taken without food). Tests and procedures requiring NPO status or that change usual patient meal times
(ADA, n. d.; ADA, 2012; Seley, et.al., 2012).

Factors Affecting Diabetes A Review in Caring

You are caring for a 42 year old woman admitted with pneumonia and diabetes Type II. She states that she just does not understand why her blood sugar is higher than usual while she is in the hospital since she is not consuming any more food than usual. As her nurse you explain:
A) That she must be sneaking food from visitors because there is no good reason why her blood glucose should not be controlled.
B) Acknowledge patients concern and explain that there are many things like stress, inactivity and infection that can increase blood glucose while she is in the hospital. Then assess and discuss with the patient what individually may be causing her increased glucose levels. C) That you really dont know why.

Answer
The answer is B. Rationale:
Patients are generally more sedentary while they are sick. In addition the bodys physical response to infection and emotional stress can increase the blood glucose
(ADA, n. d.; ADA, 2012; Seley,et. al., 2012).

Also using sensitivity when responding nurtures a helping & trusting relationship with the patient. This assists in collaborative problem solving, which supports the goal of recovery and self-care - Watsons Theory of Caring (Jesse, 2010).

Dietary Guidelines for Diabetes- Understanding the Basics of Carbohydrate Choices in Meal Planning Carbohydrates are one of three main energy sources in food, in addition to protein and fat.
They affect blood glucose faster than the other sources of energy. The balance between the carbohydrates consumed and the amount of insulin available determines the level of the blood glucose after meals.

Planning Carbohydrate consumption is the simplest way to manage a target glucose level
(ADA, 2012; Wollenburg, 2011).

 One Carbohydrate serving equals 15 grams of Carbohydrate no matter what the carbohydrate is, so they can be exchanged equally. Carbohydrates are important sources of energy usually available for the body 20 minutes to two hours after consumption. The amount of carbohydrates a person should eat depends on their weight, energy expenditure, medications used and age. Registered Dieticians can help a patient individualize snack and meal plans.
(ADA, n. d.; ADA, 2012; Wollenburg, 2011)

 Carbohydrates contain starch, sugar or both. Basic examples Breads and grains (15 gm = 1 slice bread or cup hot cereal), Milk and yogurt (15 gm = 1 cup of light yogurt or skim milk), Fruits and Vegetables (15 gm = 1 small banana or 4 oz of fruit juice), Sugary foods and drinks (15 gm = 2Tbsp chocolate syrup or a frozen 100% juice bar)
(Wollenburg, 2011).

Dietary Guidelines for Diabetes A Review

According to the American Diabetes Association (2012) planning carbohydrate consumption is the simplest way to manage a target blood glucose level. Which dietary guideline should you follow when helping a patient understand the basics of carbohydrate choices in meal planning?

A) One carbohydrate serving equals 15 grams of carbohydrate no matter what the carbohydrate is, so they can be exchanged equally.
B) All persons with diabetes, no matter what their weight, age, or activity level, should eat the same amount of carbohydrates with each meal. C) All patients with diabetes should be following an 1800-2400 calorie ADA diet.

Answer
The answer is A. Rationale:
The American Diabetes Association does not promote a specific diet. Instead monitoring carbohydrates, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control... It is recommended that individualized meal planning include optimization of food choices to meet recommended daily allowancefor all nutrients (ADA,
2012, S23).

Glycemic Management in Clinical Practice

Patient Outcomes
Patients will be managed to reach an acceptable blood glucose level during their hospital stay. Target blood glucose range for critically ill patients is 140-180 mg/dl, non-critically ill patients the range is above 70 mg/dl and below 180 mg/dl. Remember insulin is still the preferred treatment for treating hospitalized patients with hyperglycemia (even Type II ). Follow your Hospitals Glycemic Management Clinical Practice Guideline if the patients blood glucose falls outside this range.
(ADA, 2012)

Monitor for Iatrogenic Diabetes Complications

by Knowing the Signs and Symptoms of Hypoglycemia and Hyperglycemia

Ketoacidosis
Ketones are produced when the body burns fat for energy. This can occur when the body does not have enough insulin due to illness; or when the body does not get enough food. Ketoacidosis usually occurs in people with Type 1 diabetes but can occur in older people with Type 2 diabetes. Increased Ketones build up, which poison the body and can lead to a diabetic coma and death. Symptoms can be similar to dehydration and may include:
fruity odor on breath, short deep breaths, confusion, & high blood sugar / ketones, flushed skin, thready pulse, nausea and vomiting.

(Wollenburg, 2011).

Hyperosmolar Hyperglycemic NonKetotic Syndrome (HHNS)

HHNS is more often found in Type 2 elderly diabetic persons with an infection or illness (However, it may occur with Type 1 diabetes). The symptoms are increased thirst leading to increased urination that changes to decreased urination and dark urine. Symptoms are similar to dehydration, but may include:
blood sugar over 600 mg/dl, fever over 101 degrees F., confusion, loss of vision. (ADA, 2013).

Nursing Assessment & Interventions

Use your hospitals portable blood glucose meter, unless otherwise ordered. Always follow physician orders and Hospital Clinical Practice Guidelines: Monitor patient, report condition, provide interventions, document educate patient and significant other, repeat. Documentation should include: all glucose meter readings complete I & O, nutritional intake & carb count, insulin & diabetic meds given, signs & symptoms, pertinent observations, communications, interventions, & patient response.
(ADA, 2012)

 Hypoglycemia Guidelines
Research supports that Hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms (Maynard, Lee, Phillips, Fink, Renvall, 2009). Follow your Hypoglycemia Treatment Algorithm for Adults found in the online Clinical Practice Manual
(ADA, 2012).

 Hyperglycemia:
Obtain HgA1c for all patients with hyperglycemia,
(who have not had a documented value within the last 3months) Order via Per Protocol No co-sign Required.

Nutritional consult
(no physician order needed).

Notify physician of blood glucose values greater than 180 for patients not currently on insulin. Notify physician of blood glucose values greater than 180 x 2 within 24 hours despite current insulin treatment. Be ready:
to administer insulin, IV fluids, oxygen (for kussmaul respirations or de-saturation), lab studies (blood sugar, electrolytes, arterial or venous blood gases, Beta Hyddroxibuterate [a lab replacing serum acetones]), as per physician orders.
(HFAP, 2009; ADA, 2012)

When a Patient has an Insulin Pump

Follow your hospitals Insulin Pump Clinical Practice Guideline found in the Clinical Practice Manual:
Continuous subcutaneous insulin infusion therapy involves, an external pump that delivers a continuous flow of insulin, through a cannula placed in the subcutaneous tissue, to improve overall metabolic measures and quality of life
(NDIC, 2012; Wollenburg, 2011).

Contraindications to Insulin Pump Therapy

Patient with altered state of consciousness. Patient at risk for suicide. Patient is non-compliant. Critically ill patients requiring intensive care (e.g.,:
severe diabetic ketoacidosis, sepsis, Trauma, etc.). Always check with the physician if you have any concerns regarding patient safety.

(Medtronic, 2011)

Insulin Pump Components External pump with a disposable plastic insulin cartridge or syringe. Infusion tubing set and subcutaneous needle. Size of a deck of cards, weigh 3 oz.
(NDIC, 2012, p. 2)

Insulin Pump Guidelines

A needle and plunger are temporarily attached to the cartridge to allow the user to fill the cartridge with insulin from a vial. The user then removes the needle and plunger and loads the filled cartridge into the pump. Insulin pumps contain enough insulin for several days.
(NDIC, 2012, p. 2).

pumps are programmable to deliver: basal, rapid, or bolus insulin doses. For information regarding the Insulin Pump you can ask: the patient or significant other; the primary care or pump prescribing physician; The Outpatient Diabetes Educator; or the insulin pump manufacturer. (AADE, 2008)

Insulin Pump Management in the Hospital

Assess patient or families ability to manage the pump,

if concerns consult physician for alternative insulin therapy.

Obtain order to continue pump therapy (For elective surgical and diagnostic procedures, the pump prescribing physician should review orders with the admitting physician, and anesthesiologist. In most instances it is appropriate to continue basal rate through surgical procedure or even if patient is unable to eat (ADA 2012).
NPO patients have fewer episodes of hypoglycemia when given a lowdose dextrose infusion along with their basal insulin(Maynard, Lee, Phillips, Fink, & Renvall, 2009, p. 7). Blood glucose times for monitoring should be every 3-6 hours or more if NPO unless otherwise ordered (2012).

 Assess the subcutaneous site for signs and symptoms of infection and document.
The site needs to be changed by the patient/family with a new needle and tubing set every three days (and prn if blood glucose increases at or above 180 for 2 consecutive readings).

If the site is changed due to high blood sugar, the initial insulin dose should be administered by injection. Pump supplies are supplied by patient /family
(AADE, 2008).

 Do not place insulin pump in the direct line of X-rays (the tubing and pump can be disconnected from the catheter). Always disconnect for an MRI. Reconnect ASAP. If disconnected longer than 2 hours, check blood glucose and treat as ordered. Always follow your hospitals Clinical Practice Manual Guidelines. (Medtronic, 2011)

Document, Document, Document

Document:
Type and manufacturer of pump, and insulin used All rates: Basal, bolus, rapid dose rates Pump status, on or off Site location and appearance every shift and PRN Intake of Carbohydrates Patient signs and symptoms of any complications and treatment / interventions
(NDIC, 2012; AADE, 2008)

A Diabetic Treatment Review Question

True or False: It is contraindicated to continue an insulin pump on a patient who is NPO or going through a surgical procedure.
True False

Answer
The answer is False. Rationale: In most instances it is appropriate to continue a basal rate through a surgical procedure or even if a patient is unable to eat. However an order is needed to continue pump therapy. For elective surgical and diagnostic procedures, the pump prescribing physician should review orders with the admitting physician and anesthesiologist (). Remember, NPO patients have fewer episodes of hypoglycemia when given a low dose dextrose infusion along with their basal insulin (Maynard, Lee, Phillips, Fink, &
Revall, 2009, p.7).

 The stress of being sick can raise blood glucose levels even if someone is NPO or they are vomiting,
monitor and notify doctor for direction re: diabetic medications. Illness can make it difficult to eat,
however if possible the same amount of carbohydrates should be ingested as usual. If difficulty chewing or swallowing soft carbohydrates may be tried (e.g., rice, applesauce, crackers, cooked vegetables, oatmeal, toast).

If nauseated may try sipping on clear liquid carbohydrates every 10 to 15 minutes (e.g., regular soft drinks, jello, apple juice, gatorade, broth or popsicles).
If nauseated with a blood sugar over 240 mg/dl try sugar-free liquids (in addition notify MD as insulin may be ordered).

(Wollenburg, 2011).

Teaching Diabetes Survival Skills at Home

How to deal with sick days:
Generally increase blood glucose monitoring every 2 to 4 hours @ home for both Type I and Type II Diabetes. For Type 1 Diabetic Patients: monitor ketones every 4 hours at home if:
blood sugar is 240 mg/dl in the AM, or 300mg/dl at other times if they have a fever, or if vomiting, or if an insulin dose is missed. (In the hospital ketones are usually ordered with a UA or the PH of the blood is checked).
(Wollenburg, 2011; Covenant HealthCare, 2009)

Teach How to Treat Hypoglycemia at Home

If alert and blood glucose falls below 70 (with or without symptoms): Eat 15 grams carbohydrate, wait 15 minutes and retest. If blood glucose remains below 70, repeat treatment with another 15 grams carbohydrate. Glucose in normal range but If more than 1 hour to next meal or snack, add additional 15 grams carbohydrate and a meat choice to maintain blood (e.g., a meat sandwich or about 5 crackers and 1 oz. cheese). If blood glucose is < 50 add 30 grams carbohydrate. 15 grams carbohydrate (without added fat) should increase blood glucose levels 50 to 100 points in 15 minutes
(Wollenburg, 2011).

Severe Hypoglycemia
For patients with Type 1 diabetes or Type 2 on Insulin:
Make sure patient has a prescription for a glucagon kit and a trained family member to administer it if needed:
If having seizure or unconscious - related to hypoglycemia. (ADA, 2012)

Some 15 gram Carbohydrate Choices

3 square or 4 round glucose tablets of a 31 gram tube of Insta-glucose 8 lifesavers candies One 12oz can of V-8 or tomato juice 1 Tblsp of honey or corn syrup

Cup regular soft drink, kool-aid, or apple juice

1 Tblsp sugar = 3 sugar packets= 5 sugar cubes

(Wollenburg, 2011)

Diabetes Survival Skills A Review

Your patient who is newly diagnosed with diabetes is going to be discharged tomorrow. To prepare your patient for discharge you give them their Diabetes Education Booklet. In addition you take time to review with the patient how to deal with sick days at home. It is important to explain to the patient that sometimes illness can make it difficult to eat, however if possible the same amount of carbohydrates should be ingested as usual. Based on this principle which guideline below is correct to share with your patient? A) If nauseated they can only sip on sugar free drinks because they have diabetes. The fluid itself is what is important. B) If nauseated they may try sipping on clear liquid carbohydrates like regular soft drinks, jello, apple juice, Gatorade, broth, or popsicles every 10 to 15 minutes. C) Even if their nauseated they must force themselves to eat solid foods anyway because they have diabetes.

Answer
The answer is B. Rationale:
Only if their blood sugar is over 240 mg/dl should they sip on sugar free liquids when they are nauseated. The key is to avoid hypoglycemia with steady slow ingestion of liquid carbohydrates
(Wollenburg, 2011).

Reinforce Diabetic Self-Management Principles

Stress the importance of: Regular physical activity because it affects overall glycemic control through improved insulin sensitivity, lowered insulin requirements, and improved glucose tolerance (Hayes, et. al., 2012).
First get doctors approval. Begin gradually perhaps 10 min 3 x week. Goal for most is 150 min of moderate Activity / week (e.g., walking). Expect setbacks, just restart when it is ok with your doctor. Do not exercise if you are sick or have ketones in your urine
(Wollenburg, 2011).

 Vaccinations:
annual influenza vaccine, Pneumococcal polysaccharide vaccine(s), and hepatitis B vaccine (AADE, 2012; ADA, 2012).

Foot care:
Do not go barefoot & examine feet daily for cracks or discoloration (the assistance of a mirror or other person may be needed), see a podiatrist or PMD for any concerns found immediately.

Oral care:
see a dentist 2 x year, and brush twice a day, and floss daily.

Eye exams yearly, including a retina exam. Educate on risks of smoking & offer resources to help them quit. Review increased health risks related to diabetes such as:
kidney disease, CAD, retinopathy, gastroparesis, & neuropathy

(ADA, 2012; Wollenburg, 2011).

Why Diabetes Affects Wound Healing

Elevated blood glucose levels:
Stiffen the arteries and cause a narrowing of the blood vessels which in turn,
o decreases blood flow, which then affects the ability of white blood cells to fight infection and red blood cells which carry oxygen to get to the wound;

Decrease the function of red blood cells affecting distribution of nutrients to the cells; Research supports that some hormones and enzymes respond to an elevated blood glucose resulting in a negative affect on the immune system. These reasons slow healing rates and increase chances of infection
(Wound Care Centers, 2013)

 Therefore teaching to improve healing is important!

Emphasize the importance of a regular well balanced diet and to take medications as prescribed. Teach prevention by emphasizing the need for the patient to avoid pressure points with good fitting shoes and daily skin checks. Keep any pressure off a wound. If ok with the doctor encourage exercise to help decrease chronic inflammation, blood glucose and weight. Emphasize why quitting smoking would improve circulation in the blood vessels.
(Wound Care Centers, 2013)

Diabetes Self-management Principles Review

Teaching Diabetes Self-management Principles is an important part of patient care and can begin or be reiterated in the hospital setting. In addition to referring the patient to a outpatient DSME program which of the following Diabetes Self-management Principles is INCORRECT:

A) Regular physical activity helps improve glycemic control.

B) Yearly influenza vaccines and eye exams are an important part of prevention and health maintenance. C) Quitting smoking is critical to improving the circulation of blood flow in the vessels and affects wound healing. D) When educating a patient how to inject insulin subcutaneously. always teach to aspirate back before injecting.

Answer
The answer is D. Rationale:
Aspiration is considered an unnecessary step when teaching self-injection of insulin, as no adverse effects have been noted by eliminating this part (Perry & Potter,
2010).

The rest of the principles (regular physical activity, yearly flu vaccines and eye exams, and quitting smoking) as listed in answer options A-C are among some of the important guidelines that should be shared with patients with diabetes
(ADA, 2012; Wollengburg, 2011).

Educate, Educate, Educate

Provide Diabetes Education Booklet for Adult patients with diabetes or; Provide appropriate Obstetric Diabetes Education materials for pregnant patients with diabetes. Also, refer patient and significant other to your hospitals outpatient DSME program.

Education Evaluation Form

Were the following concepts reviewed and objectives met?
Proper diabetic terminology - explain the difference between Type I & Type II Diabetes:
Yes No

Common and latest diabetes treatments reviewed able to identify a contraindication for a patient using an insulin pump in the hospital setting:
Yes No

Common diabetic medications able to describe the difference between two diabetic medications.
Yes No

Factors affecting diabetes able to name three factors that can affect blood glucose levels.
Yes No

Education Evaluation (continued)

Dietary guidelines in diabetic management able to relate on carbohydrate dietary guideline in meal planning: Yes No Patient diabetes survival skills able to state one recommendation for self-care during sick days: Yes No Diabetes self-management principles - able to recall four selfmanagement principles to teach your patient: Yes No

 How effective was this online method of learning for you?

How long did it take you to complete this independent online education program?

Was this information presented without bias?

(Ohio Nurses Association, 2012, Evaluation Form)

References
American Association of Diabetes Educators. (2008). Insulin pump therapy: Guidelines for successful outcomes. Retrieved from www.diabeteseducator.org American Association of Diabetes Educators. (2012). Vaccination practices for hepatitis B, influenza and pneumococcal disease for people with diabetes; Position statement. Retrieved from http://www.diabeteseducator.org. American Diabetes Association (2012). Standards of medical care in diabetes-2012. Diabetes Care, 35(S1), S11-S63. Retrieved from http://care.diabetesjournal.org American Diabetes Association (n. d.). Choose to live: Your diabetes survival guide. [Booklet], (pp. 1-32). Retrieved from www.diabetes.org American Diabetes Association (2013). Hyperosmolar, Hyperglycemic Non-Ketotic Syndrome. Retrieved from http://www.diabetes.org/living-with-diabetes/complications

Brown, T. L., Childs, B. P., Funnell, M. M., Haas, L. B., Hosey, G. M., Jensen, B. (2011). National standards for diabetes self-management education. Diabetes Care, 34(1), p. S89+. Retrieved from http://dx.doi.org/10.2337/dc11-S089 Centers for Disease Control and Prevention (2011). National diabetes fact sheet: National estimates and general information on diabetes and pre-diabetes in the United States. [Leaflet], (pp. 1-12). Atlanta, GA: U. S. Department of Health and Human Services. Retrieved from www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf

Covenant HealthCare (2013). About covenant. Retrieved from http://www.covenanthealthcare.com

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