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DAILY LIVING WITH DIABETES
INPATIENT EDUCATION
K AT HLE E N D E A N G E LO R N ,
MSN/MBA/HCM
CYNTHIA HALE RN
JULIE ZIGADLO RN, BSN
OBJECTIVES
Understand your role and opportunities to improve your patients understanding and
self management of Diabetes at home.
Identify 3 key elements how to develop a patient centered approach to educating an
in-patient with Diabetes.
Identify the basic “Survival Skills” your diabetic patients need to know.
OPPORTUNITY
Hospitalization
 Address Urgent learning needs for Diabetic Patients
 Studies reveal that Diabetes has a tendency to be neglected in the hospital
 Hyperglycemic events often are missed opportunities for education in the hospital.
IMPROVED SELF-CARE EDUCATION
Improve the patient’s ability to solve problems at home
Improve the patient’s ability to better control blood glucose levels.
Improve the overall quality of their everyday life with Diabetes.
APPROACHING EDUCATION
Diabetes diagnosis changes a person’s identity
Our role is to:
 help the patient identify barriers to learning and lifestyle/behavior change
 Provide knowledge and assess skills
 Facilitate problem solving and coping skills to improve quality of life
Adult learners
 Problem oriented
 Need to actively participate in learning
 Needs to be relevant to their lifestyle and culture
 Involve family member or other support person
FACTORS THAT IMPACT DIABETES
EDUCATION FOR AN INPATIENT
Physical Condition
Engagement in learning
Culture
Mental health
Lack of interest
Financial situation…knowledge, learning, self-care
KEYS TO EFFECTIVE EDUCATION
As an RN you must be non-judgmental
Avoid negative words.
 Non-compliance
 Bad Blood Sugars
 Failure
PATIENT-CENTERED APPROACH
Very Important to always start with the patient’s agenda or goals in mind.
Provide for empathetic listening. Establishing eye-contact with the patient. If possible
be at eye level and sit next to the patient.
Ask open-ended questions, never approach a patient by lecturing or telling what the
patient “should” do.
SELF-CARE BEHAVIORS
The American Association of Diabetes Educators (AADE) believes that behavior
change can be most successfully achieved when patients follow seven self-care
behaviors.
The Joint Commission (JC) and American Diabetes Association (ADA) focus on predischarge assessment and education content.
ASSESSMENT
The first step in the education process
 Assess what the patient already knows, ask what their concerns are and address
them; start with the patient’s agenda.
 Pre-Survival Skills
 When and how to take medications
 Consistent eating patterns
 Ability/resources for some home testing
 Know symptoms of hypoglycemia
 Know who and when to call for help
WHAT DO I TEACH FIRST?
Teach the basics that a patient absolutely needs before they go home such as:
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How to check blood sugar
When to check blood sugar
How to identify and treat hypo/hyperglycemia
Nutrition and carb counting
Importance of screenings and follow-up appointments
TEACHING TECHNIQUE
Patients forget
50% of what is learned in a doctors office by the time they reach the parking lot
Patients retain
90% of what is said while performing the action
Offer opportunities to practice skills during teaching
Role playing, return demonstration, discussion, games/technology, and conversation
maps
MONITORING
70-140 is the pre-meal target range for most Adults, but may be individualized
depending on factors such as BG fragility (“brittle diabetic”), comorbidities, etc.
A1c target < 7.0%
Lipids- target LDL <100, HDL >40-50, triglycerides <150
 #1 lifestyle modification- reduce saturated, trans fat and cholesterol intake, weight
loss, exercise, increase plant sterols and viscous fibers
 statins
BP target <140/80
 DASH diet, 1st line meds ACEI or ARB (2+ agents at max dose usually required)
HYPOGLYCEMIA
Adrenergic/cholinergic s/s- treat with 15g of carbs/4glucose tabs/15g glucose gel
and recheck in 15min until BG>80 with s/s or >100 with s/s then recheck
again in 1h
 Mild- Pallor, sweating, tachycardia, palpitations, hunger, shakiness
 Moderate- Slurred speech, slowed reaction time, blurred vision, somnolence,
fatigue, repetitive movements
Severe- treat with glucagon SC or IM 1mg if >44lbs or D50 IV
 Disoriented , loss of consciousness, seizure, inability to rouse
If hx. of asymptomatic hypoglycemia, A1c goal may need to be increased
HYPERGLYCEMIA
BG >180
 Risk for DKA, HHS (Hyperosmolar hyperglycemic state) or chronic vascular
complications
 Increased platelet adhesion, decreased chemostaxis (WBC response to
infection), increased blood viscosity
s/s
 Hunger, thirst, frequent urination, blurry vision, shoulder girdle pain, weakness,
somnolence, nausea and vomiting, abdominal pain, cramps, burping, hiccuping
 Recurrent UTI’s, dehydration, hypotension, tachycardia, hyperventilation,
ketonuria, ketone breath, weight loss, impaired consciousness
BLOOD GLUCOSE TESTING
Each patient may be assigned to test at different times, but the most common times
are:
 AC, PC, HS, overnight (3am usually), and when exercising
 TID is suggested, but there are no standards for NIDDM testing frequency
If have normal pre-meal values but A1c elevated, check post meals. Target is only a
30-60mg/dl increase from pre-post meal rise
BG TEST TECHNIQUE
Rotate sites
 Put palms of hands together, and the area exposed is where you can test, on the
sides of the fingers
 Can also test on thighs, palm of hand, side of arm with certain devices
Clean hands with soap and water
Alcohol on the finger can decrease BG, lotion can increase BG
Use the shallowest lancet setting to get enough blood
Hold finger for >10s after to ensure no bleeding after
SICK DAY RULES
Check BG Q2-4h, monitor for weight changes, assess respirations, check urine
ketones Q4h
Force fluids 16oz/hr to replace losses
Electrolytes: diluted broth, Pedialyte, Gatorade, diluted fruit juice
Replace Carbs if can’t eat solids
 If high BG: choose sugar free liquids
 If low or normal BG: choose carb liquids (min carb intake >130gm/day
 15g carb: 4-6oz regular soda, 1/2cup regular gelatin, 1/4cup sherbet, 1 cup
milk
SICK DAY INSULIN
Most patients need to take insulin even if not eating (IDDM always needs insulin)
If ketones present, extra insulin needed
If vomiting, may need to replace basal insulin with rapid acting insulin
NIDDM may require insulin temporarily
SICK DAY RULES (CONT)
Call MD if:
 BG >300 for >6h
 Ketonuria
 Signs of dehydration
 Signs of ketoacidosis (nausea is a good indicator, vomiting)
 Inability to eat or drink for 4h
MEDICATION ADHERENCE
Medication regimen may change while a patient is in the hospital and then a patient
may be discharged home on insulin.
Education regarding when to test and how to medicate with insulin should begin as
soon as possible during the patients admission.
Be sure to ask the patient about their concerns regarding insulin.
Review hypoglycemia , its prevention, recognition and treatment.
HEALTHY EATING
Consult nutrition
Refer to Diabetes Center for MNT (medical nutrition therapy)
Diabetes management requires a balance between protein, fats, and carbs
Incorporate patients absolute needs in a diet (allow foods that patient feels
necessary and reduce non-necessary excess carbs); consider cultural needs
HEALTHY EATING
Protein- contains essential amino acids, 4ckal/gram calories,
 minimal effect on post meal BG,
 basal insulin covers protein eaten, not recommended to treat hypo BG,
 adds calories but doesn’t sustain elevation of BG
Fat-9cal/g calories,
 basal insulin covers fat eaten,
 minimal post meal impact on BG,
 high fat meals promote insulin resistance, raises BG 5h later,
 beware of saturated fats such as those with baking or cooking
Carbs- body’s preferred fuel source need a minimum of 130g carb/day, immediate and
direct impact on BG.
 Complex and Simple Carbs
Fiber Insoluble and Soulable
EXERCISE
7% weight loss reduces diabetes risk by 58%
5% weight loss in diabetes improves CV risk factors, insulin resistance, lipemia and
BP
150min/week moderate intensity aerobic activity at 50-70% of max heart rate over
3days/week, no more than 2 days without exercise
Resistance training 2x/week
PREVENTING COMPLICATIONS
Quit smoking- increases risk for comorbidities (primarily cardiovascular) and death,
increases risk of CAD by 54% and stroke by 29%
Foot care- annual podiatrist f/u, check feet daily with a mirror, do not wear shoes or
socks that rub, file nails straight across, do not cut
PROBLEM SOLVING
Going through possible scenarios with patients allows them to develop their own
problem solving skills in managing their diabetes every day.
 Identify the problem, be specific
 Consider alternatives to address the problem
 Evaluate the alternatives, pros and cons.
 Pick the best strategy
 Try it and then evaluate it if worked. If not then try another strategy
LIFESTYLE, HEALTH COPING
Dealing with life and coping with Diabetes is all about decision making.
Self-Care is challenging as it disrupts daily living of a person.
Ensure you educate your patient on using other coping skills to have a Healthy
Lifestyle. Community resources, imagery, humor, exercise etc.
CASE STUDY A
Presenter: Julie Zigadlo RN, BSN
47 yr. old male, from home presents to the emergency department with the following
symptoms:
Increased thirst, increased frequency of urination, and weakness as well as feeling
“hot”. The initial finger stick was 402.
I.V. fluids were started and 2u regular insulin given IV and 10u Lispro given sc.
When the patient arrived to the in-patient unit their finger stick was 233 and the
patient stated that they were feeling better.
The patient had been diagnosed with diabetes a few months earlier and started on
glucophage, he was never educated about his diabetes. The night RN was
reporting that he was reluctant to accept teaching.
How did we approach the Survival Skills Education for this patient?
CASE STUDY B
Cynthia Hale, RN
45 yr. old female admitted with polyuria, diaphoretic and a finger stick of 600.
She has been taking 1000mg of metformin twice daily and she reports her home
blood sugars are consistently high.
The patient is admitted to the medical unit for management of her diabetes.
The patient is eager to learn how to better manage her diabetes at home and prevent
a re-occurrence of coming to the hospital for her “high” blood glucose.
HbA1c is 7.3% , taken in the last 30 days.
How did we approach the Survival Skills education for this patient?
IN SUMMARY
Listen and collaborate with the patient for the best outcome with education
Address the 7 crucial concepts, healthy diet, activity, medication, blood glucose
monitoring, problem solving,(sick days), healthy coping, and reducing risks.
Provide your patient with outside resources to support on-going lifestyle change and
managing life with Diabetes.
REFERENCES:
Lien,Lillian F., Cox, Mary E., Feinglas, Mark N., Corsino, Leonor. Glycemic Control in
the Hospitalized Patient. 2011; 5:42-48.
American Association of Diabetes Educators (AADE). Inpatient position statement.
http;//www.diabeteseducator.org/ProfessionalResources . Accessed March 11,
2015.