Download INPATIENT BLOOD GLUCOSE CONTROL

BLOOD GLUCOSE
CONTROL
A learning module for
NURSING ASSISTANTS
at Saint Joseph Health System
Developed by: Dana Graves RN, MSN, CDE
Diabetes Clinical Nurse Specialist
December 2008 revised
INPATIENT BLOOD
GLUCOSE CONTROL
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1.
2.
This learning module is required for orientation to
Diabetes Care and blood glucose control issues here at
Saint Joseph Health System. This can also be used for
periodic review as needed.
The purpose of this module is:
To discuss the importance of blood glucose control in the
hospital.
To orient you to the policies and procedures used for
inpatient blood glucose control appropriate to your role.
At the end of this module,
you will take a 10 question post-test.
DIABETES RELATED
PREVALENCE DATA
WHY IS BLOOD GLUCOSE CONTROL SO IMPORTANT
IN THE HOSPITAL SETTING?
 Diabetes has reached epidemic proportions in the U.S. affecting
more than 20 million people.
 More than 300,000 Kentuckians have diabetes.
 One in two Kentucky adults are at risk for developing diabetes.
 Diabetes is the 5th leading cause of death in Kentucky.
 Nationally, about 5,000 adults are diagnosed every workday.
 Diabetes is the leading cause of blindness, non-traumatic
amputations, and end-stage renal disease.
 With diabetes, the risk of heart disease and stroke is 2 to 4 times
higher than those without diabetes.
Therefore, we will see more and more patients who have a
diabetes diagnosis and/or blood glucose problems.
DIABETES RELATED
RESEARCH
RESEARCH SHOWS THAT BLOOD GLUCOSE
CONTROL IN THE HOSPITAL WILL HELP
DECREASE MORBIDITY (illness) AND MORTALITY
RATES
For Example:
Hyperglycemia and:
Myocardial Infarction
Stroke
Cardiac Bypass
General Surgery
Can lead to:
Increased mortality risk
Greater disability risk for those admitted with
a blood glucose of >120mg/dl; and, Doubles
the mortality risk
Increased mortality rate and increased sternal
wound infections
Increased risk of serious infections (six-fold)
DIABETES RELATED
RESEARCH
“Diabetes increases the risk for disorders that
predispose individuals to hospitalization,
including coronary artery, cerebrovascular and
peripheral vascular disease, nephropathy [kidney
disease], infection, and lower-extremity
amputations. Recent studies have focused
attention to the possibility that . . . aggressive
treatment of diabetes and hyperglycemia results in
reduced mortality and morbidity.”
Clement, S., Braithwaite, M., et al. Management of Diabetes and Hyperglycemia in
Hospitals. Diabetes Care, volume 27, number 2, February 2004, p. 553.
DIABETES RELATED
RESEARCH
Two landmark research studies (DCCT and UKPDS) showed that keeping
blood glucose levels close to normal slowed the onset and progression
of eye, kidney, and nerve diseases.
 The Diabetes Control and Complications Trial (DCCT) was a clinical
study that involved over 1400 people with Type 1 diabetes.
 DCCT Study findings included:
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76% risk reduction in eye disease
50% risk reduction in kidney disease
60% risk reduction in nerve disease
35% risk reduction in cardiovascular disease
 The United Kingdom Prospective Diabetes Study (UKPDS) involved
over 5,000 people with Type 2 diabetes. It also showed similar risk
reductions.
DIABETES RELATED
RESEARCH
Then in 2003 and again in 2006, the American
Diabetes Association (ADA) and the American
Association of Clinical Endocrinologists (ACE),
based on clinical trial results, made
recommendations for the management of
hyperglycemia in the hospitalized patient.
Based on this data and more, Saint Joseph
Healthcare has made the commitment to inpatient
blood glucose control for ALL patients regardless
of diabetes diagnosis or not.
BLOOD GLUCOSE CONTROL
Therefore, SJHS’s current policies, procedures, protocols, and
documentation forms reflect the need for inpatient blood glucose
control. They include:
Protocols and Standing Orders:
 Blood Glucose Control
Protocol
 Hypoglycemia Protocol(s)
 Perioperative Blood Glucose
Control Protocol
 Insulin Pump Standing Orders
 DKA Standing Orders
 Non Critical Care IV Insulin
Drip Standing Orders
 Critical Care IV Insulin Drip
Standing Orders
 SQ Insulin Standing Orders
Documentation Forms:
 Blood Glucose Section of the Patient
Care Flowsheet
 MAR
 Blood Glucose Hourly Flowsheet
 Patient Discharge Instructions sheet
 Admission History (peach color sheet)
 Treatment Plan: Diabetes section
 Interdisciplinary Consult and Education
Record
Policies and Procedures include:
 Insulin Preparation and Administration
Procedure
 Insulin (Pharmacy policy)
 Use of Patient Owned Equipment while
Hospitalized
 Use of Blood Glucose Control /
Diabetes related protocols
BLOOD GLUCOSE CONTROL
That’s quite a list isn’t it? Be assured we are
not going to go through all of those.
We will just look at those policies, procedures
and protocols that may impact your role as a
Nursing Assistant/SWAN.
But before we move on, it would be important
for you to know what is normal blood
glucose and what isn’t.
BLOOD GLUCOSE TARGET
According to SJHS’s laboratory, blood glucose
should be in the range of 65 to 110mg/dl.
However, because we do things in the hospital to
raise that blood glucose, SJHS’s inpatient target
blood glucose for people with diabetes is 70 to
180mg/dl for med/surg patients. Critical Care
patients have a tighter blood glucose goal of 80 to
110mg/dl.
It will be important for you to remember
these goals!
BLOOD GLUCOSE
CONTROL PROTOCOL
As we said earlier, all hospitalized patients who have
diabetes or patient’s without a diabetes diagnosis
yet who have a blood glucose level above normal
are at increased risk of not healing well, not
feeling well, or dying when their blood glucose
remains elevated.
Therefore, to help prevent this, the Blood Glucose
Control Protocol was developed for all patients
who have been admitted with diabetes and any
patient with a blood glucose of 150mg/dl or
greater, regardless of diabetes diagnosis or not.
BLOOD GLUCOSE
CONTROL PROTOCOL
One of the orders this protocol provides, is an order
for FSBG (finger stick blood glucose).
It is very important to do FSBG as ordered. Most of
the time it is ordered to be done before meals and
at bedtime. If the patient is NPO or on tube
feeding, then FSBG’s will be done every 6 hours
instead.
The doctor will base his/her treatment on what the
blood glucose has been doing over the course of
the day. So, accurate checking, documenting,
and reporting to the nurse is vital!
BLOOD GLUCOSE CONTROL
We don’t want the blood glucose to be too high or too low.
So, if one of your responsibilities is to actually do the FSBG,
then it will be extremely important to immediately report
ALL FSBG’s to that patient’s nurse.
When taking a FSBG, you must always put in The
Intervention Code # 45 - “Reported result to nurse”.
The nurse may have to give insulin or food to the patient
depending on the blood glucose number.
***If the patient is on an IV insulin infusion, then FSBG’s
may need to be taken every hour. These then need to
be documented on the Blood Glucose Hourly
Flowsheet.
BLOOD GLUCOSE CONTROL
Regardless of whether your role includes
checking the FSBG or not, it will be
important to report to the nurse any signs or
symptoms that may indicate too high or too
low FSBG.
So, what are those signs/symptoms to
watch for?
BLOOD GLUCOSE CONTROL:
Hyperglycemia
High Blood Glucose (Hyperglycemia) may be a bit hard to
detect just based on symptoms. The patient just
may not feel well. But other common
signs/symptoms may also include:
 Tiredness; Fatigue
 Increased thirstiness; Increased hunger
 Going to the bathroom more often
 Confusion
 Blurred vision
 Recurrent infections
 Weight loss
BLOOD GLUCOSE CONTROL:
Hyperglycemia
Insulin injections are the treatment of choice for high
blood glucose.
The Blood Glucose Control Protocol has insulin
injections orders for when the FSBG is greater
than 120mg/dl.
If the FSBG remains very high, an IV insulin drip
may have to be started.
KEY POINT:
It is very important that you report ALL blood
glucoses and sign/symptoms to the nurse.
HYPOGLYCEMIA PROTOCOL
The Hypoglycemia Protocol was developed to provide
treatment for patients who have low blood glucose.
Mild/Moderate Hypoglycemia is defined as:
FSBG 41 – 69mg/dl whether symptomatic or not
Severe Hypoglycemia is defined as:
FSBG 41 – 69mg/dl if patient has mental changes
or is unconscious; or when the
FSBG 40mg/dl or less
KEY POINT:
So, low blood glucose is treated when it is less than
70mg/dl.
HYPOGLYCEMIA PROTOCOL
Hypoglycemia symptoms may include any or all of the
following:
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Shakiness, anxiety, nervousness, tremors, palpitations
Sweating
Hunger; nausea/vomiting
Depression
Irritability
Personality changes
Confusion
Staring
Slurred speech
Fatigue; weakness
Anytime the patient has any of these signs/symptoms, please
report that to nurse so he/she can come and assess that
patient and treat what is going on.
HYPOGLYCEMIA PROTOCOL
This protocol does not need a physician’s order to
implement it.
The nurse will start this protocol based on the
FSBG number and the signs/symptoms the
patient may be experiencing!
KEYPOINT:
Tell the nurse the FSBG and any signs/symptoms
the patient has, so treatment can be started
immediately!
OTHER CARE ISSUES FOR
PATIENTS WITH DIABETES
Besides checking FSBG and observing for high and
low blood glucose symptoms, there are several
other things to remember when caring for the
patient with diabetes or blood glucose problems.
These include:
 Taking an accurate height and weight
 Making sure the patient gets his/her meal tray and
snacks on time
 Encouraging movement
 Providing good skin and dental care
 Protecting the Insulin pump
WHAT TO DO WHEN A
PATIENT IS ADMITTED
The nurse will use the Admission History sheet (peach color sheet)
upon admission. This form has a place for height and
weight. It will be important to get an accurate height and
weight as some medication doses may be determined
based on the patient’s height and weight.
This form also has an Endocrine section where the type of
diabetes is documented and when the patient was first
diagnosed with diabetes.
The nurse will ask the patient questions about his/her home
care as it relates to their diabetes.
Sometimes a referral to the Diabetes & Nutrition Center may
be done if the nurse determines that patient may need extra
help with his/her diabetes care. So that’s when you might
see the Diabetes Educator visit the patient.
TREATMENT PLAN
As you may know, the Treatment Plan (kardex)
(printed on a hard paper stock) is used by the
nurses to help with giving report!
This form would be a good reference for you to see
what kind of care issues there are for the patient.
On the Diabetes section type of diabetes and FSBG
frequency is documented.
The back of the Treatment Plan has a lined section
that is used for reminders for diabetes care / blood
glucose control issues such as teaching needs,
teaching done, insulin pump rates and set changes,
etc.
TREATMENT PLAN
The Treatment Plan will also tell you what kind of diet the
patient should have (the nurse will have shared this with
you as well).
There is no longer such a thing as a diabetes diet or an ADA
diet. The patient will be on what is called a Consistent
Carbohydrate diet. This means that the patient will get his
carbohydrates spread consistently out over the course of all
his/her meals and snacks for a 24 hour period.
Checking the patient’s FSBG, giving the insulin, and eating
the meal on time is very important for any patient with
diabetes.
Why? Well let’s explore that.
TIMING OF FSBG, INSULIN,
AND MEALS
The timing of checking a patient’s blood glucose is important
in relation to the meal. It’s important to check it
right before the meal and report it to the nurse.
The nurse will need to know the FSBG in order to determine
whether insulin is needed or not. And depending on the
type of insulin, the nurse has to give it right before the
meal or up to about 30 minutes before the meal.
KEY POINT:
If you are the one to check the FSBG,
then it will be your responsibility
to let the nurse know what the FSBG was.
TIMING OF FSBG, INSULIN,
AND MEALS
Accurate intake and output is also important!
We often need to encourage the patient to eat
especially if he/she is receiving insulin.
Sometimes if the patient does not eat enough and
insulin is given, then low blood glucose could
occur.
KEY POINT:
Encourage and help your patients eat their meals.
Document and/or tell the nurse of the patient’s
intake.
EXERCISE/MOVEMENT
Exercise is considered part of the treatment
goals for someone who has diabetes. So,
while the patient is in the hospital,
movement of some kind will be important.
Always check with the nurse regarding the
patient’s activity. It may be just turning the
patient, or getting them into a chair several
times a day or even walking the hallways.
SKIN CARE
Skin problems can occur with someone who has diabetes and
higher blood glucose levels than normal. Bathing and
providing lotion will be important for good skin care.
While bathing the patient, report to the nurse any cuts or
abrasions that are not healing well or excess bruising or
any other unusual skin problem you see.
Turning bed ridden patients on schedule will help to prevent
skin breakdown.
Making sure the patient gets enough to drink also helps to
keep the skin hydrated and helps prevent problems in the
long run. So, please make sure the patient has enough
water at the bedside and can reach the water container
and/or glass.
DENTAL CARE
We often forget about caring for the patient’s
mouth. Well, with diabetes and blood
glucose issues, gum disease and teeth
problems can frequently occur.
Please remember to help your patients brush
their teeth and use mouth wash.
Dentures should be cleaned and rinsed once a
day also.
WHAT TO DO WHEN YOUR
PATIENT HAS AN INSULIN PUMP
The nurse will follow the External Insulin Pump standing
orders for the patients who have an insulin pump.
The insulin pump is a small insulin delivery device (about the
size of a pager). It gives insulin continually. Also the
patient can take extra insulin doses through it.
More than likely the patient will keep his insulin pump on.
It is important to protect this pump and not pull it out. If it
happens to come out, notify the nurse so he/she can make
sure it gets restarted.
KEY POINT:
The patient can not be off the insulin pump for more than
an hour!
THE FINISH LINE!!!
CONGRATULATIONS!
You have finished the
Blood Glucose Control
Learning Module
If you have any questions, please contact your
Clinical Educator, your unit’s Diabetes Champion,
or one of the Diabetes Educators.