How to provide quality diabetes care
Techniques will work even with fewer visits
New knowledge, medication, and technology have made it easier to teach and help diabetes home care patients, as long as home care nurses stay up-to-date with the changes.
The new way to educate diabetes patients is to teach them how to focus on carbohydrates, not sugars. Also, while fasting glucose levels still are used to screen potential diabetics, the more useful blood test for monitoring type 2 diabetes is the hemoglobin A1C, says Linda C. Pearce, RNC, BSN, MEd, CDE, a Brandon, MS, consultant to Complete Patient Services and the Diabetes Foundation of Mississippi.
Home care nurses can teach their patients to better maintain their diabetes by focusing on their blood glucose, blood pressure, and weight and by showing them how to count their carbohydrate ingestion.
Pearce provides these tips on what to emphasize when visiting a diabetes patient:
• Explain the various target goals. Physicians typically will give diabetes patients some target goals for their blood glucose, as well as for their blood pressure, lipoprotein levels, and weight. The home care nurse can explain what those tests mean.
For example, a type 2 diabetic likely will need to monitor blood glucose levels after meals, sometimes before meals, and before bed, using one of the needle-prick self-monitoring tests or a new test that doesn’t require a needle prick. The American Diabetes Association recommends that the preprandial (before meal) goal for whole blood glucose levels should be 80-120 mg/dl, and the bedtime goal should be 100-140 mg/dl.
The physician may give the patient the hemoglobin A1C test at various times throughout the year. That shows what a person’s average blood sugar has been over the past three months and gives a good indication of whether a person has been eating too many carbohydrates.
"What happens is a person’s red blood cell has a life span of 90 days, and during the course of that life span, the blood sugar sticks to it in an
irreversible fashion," Pearce says. "With the hemoglobin A1C test, the lab can see how much sugar
has stuck to that cell over the past three months."
Recommended blood pressure goals typically are systolic readings of less than 130 mmHg and diastolic readings of less than 85 mmHg.
Because diabetics often die of heart disease, their physicians also will monitor their lipoprotein levels, and nurses can explain what those measurements mean. For instance, what is typically called the "bad" cholesterol, the LDL cholesterol reading ideally should be below 100 mg/dl, and the "good" cholesterol, the HDL cholesterol, should be above 45 mg/dl. Triglycerides, which also indicate potential problems, ideally should be less than 200 mg/dl.
Losing weight isn’t top priority
Weight goals will depend on the individual patient, but Pearce says she doesn’t place as much emphasis on patients’ losing weight because it will be harder for them to do while they are taking diabetes medications.
• Show patients how to count carbohydrates. First, nurses should find out what patients are eating and drinking throughout the day. Have them list everything, including the kinds of things they might not think are important, such as fruit juice, milk with cereal, or lemonade.
Then teach patients the "ATT" plan, which stands for amount, time, and type, Pearce says. "Patients need to look at the amount of food or serving they eat, the type of food, such as if it’s a carbohydrate, and the time of day they eat it," she explains. "Are they eating at a time when they can exercise afterwards?"
Many diabetics still think they will be OK as long as they avoid sweets and eat sugar-free foods instead. That isn’t true, and the home care nurse needs to explain that it doesn’t matter how much sugar a food item has, but how many
carbohydrates.
"One tablespoon of sugar equals one slice of bread equals one carbohydrate serving of 15 grams," Pearce says. "That will raise their blood sugar between 30 and 50 mg/dl within 15 to 30 minutes."
Pearce teaches patients how to count their carbohydrates and stick to a three- or four-carb serving, equivalent to 45 to 60 g of carbohydrates, per meal. Some vegetables, such as broccoli, greens, lettuce, and cabbage, do not count toward the carb serving because their carbohydrate grams are low and they contain needed fiber. Other vegetables, such as carrots and peas, must be counted.
Patients may be surprised to learn they also should count milk as a carb serving because one 8 ounce glass of milk is equal to 12 g of carbohydrates, regardless of whether the milk is skim or low-fat.
The typical soft drink is equal to 3.5 carb servings, and if a patient wants a soda, the regular kind should be substituted for diet soda. "But if you have type 2 diabetes and are elderly, you have to watch your caffeine intake because that dehydrates you," Pearce cautions.
Teach patients to stop thinking in terms of sugar and sugar-free, because those terms are useless to diabetics. "One of the biggest problems I see is people bringing in their sugar-free cookies or candy, which have more carbs than the ones with sugar," Pearce says.
Diabetes patients who also have cholesterol problems should be shown how to change their protein and fat intake, as well.
• Give patients ideas for exercise they can do throughout the day. People with type 2 diabetes often are obese, older, and have difficulty exercising or even walking. Home care nurses need to explain how important it is that such patients do even a little bit of exercise each day because exercise improves insulin production and reduces blood sugar levels.
"People tell you they can’t exercise," Pearce says. "But even if they can only rock a rocking chair, they can exercise."
One of Pearce’s patients liked to rock in a rocking chair, so Pearce instructed her to rock for 10 minutes after meals, going as fast as she could go, three times a day.
Another woman could only walk the circumference of the dining room table while hanging on to the table for support. Pearce had her start this walk for one or two minutes at a time. Then, slowly, she had her increase it until she could walk 20 minutes without stopping or using the table.
• Discuss other lifestyle changes. Diabetic patients need to learn how some of their habits have contributed to their disease, and they need to concentrate on developing healthy habits as much as possible. Home care nurses can supplement their face-to-face education with pamphlets and educational tools created by pharmaceutical companies and diabetes organizations.
For example, diabetic patients who smoke must stop because smoking causes as much as a tenfold increase in the risk for problems related to their hearts, kidneys, eyes, and nerves, Pearce says. Home care nurses can direct patients to smoking cessation programs and discuss the ramifications of continuing that habit.
Another lifestyle change involves teaching patients to monitor their bodies carefully for changes that could indicate infection or vascular disease. Patients need to learn how to check their feet for damage, and the home care nurse can demonstrate that for them. "Every time the patient sees a health care professional, the patient should take off shoes and socks to have the physician or nurse see how the feet look," Pearce says.
Teach patients to watch for complications
While home care nurses monitor their diabetic patients for a variety of problems related to the disease, they should teach patients how to watch out for potential complications. Those potential problems include injuries that could lead to infection, inadequate fluid intake, stress, medication problems, dental or oral infections, urinary tract infections, and blood sugar levels that fail to decrease with medication.
Perhaps most importantly, home care nurses need to make sure patients know how to check their blood sugar levels. If they fail to check these levels daily, they might miss an important change in their blood sugar trends. Such a change could mean they’ll need a different treatment.
"As the pancreas wears out, some medications that had helped do not help as much anymore, and that’s why 40% of the people with type 2 diabetes eventually need insulin," Pearce says.
It is pointless to discuss the symptoms for high blood sugar because most people either have no noticeable symptoms or they will not be able to distinguish them from symptoms they’re experiencing due to medication side effects or other causes, she says. "What I recommend is that nurses watch the patient check his or her own blood sugar to find out how the patient does it," she adds. "Do they know how to calibrate the machine? Does the meter give accurate results? Do they know where to stick the needle?"
While the home care nurse watches, the patient should complete a blood sugar check. Also, nurses may remind patients that Medicare will pay 80% of the cost of blood-sugar meters and strips, but they must be ordered through the physician, and the patient must keep a log of blood sugar results to show the physician and pharmacy.
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