Monitoring, education improve patient’s life
(Editor’s note: This is the first of a two-part series that takes a look at diabetes management for home health patients. Next month, we’ll look at how exercise, diet, and smoking should be addressed in home health diabetic patients.)
Your patient may be referred to home care as a result of stroke, cardiovascular disease, or kidney disease, but the patient also has diabetes. As you develop your care plan, be sure to include monitoring, treatment, and education about diabetes if you want good outcomes, say experts interviewed by Hospital Home Health.
"In many home care patients, a disease such as cardiovascular disease may be a complication of diabetes," says Linda C. Pearce, RN, C, BSN, a consultant with Diabetes Education Consulting in Blacksburg, VA. "If you neglect the diabetes, you are putting your patient at risk to develop other diabetes-related complications," she adds.
The good news about the prospective payment system (PPS) is that the reimbursement hasn’t changed for diabetes care, but a registered dietitian now is able to visit the patient and develop a plan to monitor and control diabetes, says Faith Thibodeau, MS, RD, LD, CDE, a diabetes educator for Visiting Nurse Service in Saco, ME.
The advantage of including a registered dietitian on the patient’s care team is that the dietitian has specific knowledge of how nutrition and other lifestyle factors interact to aggravate diabetes, she explains.
There are two types of diabetes. Type 1 usually is diagnosed in children and young adults and previously was known as juvenile diabetes. Type 2 diabetes usually is diagnosed in older adults, Pearce says.
During the assessment of a patient with diabetes, it’s important to make sure a HbA1C (glycolsylated hemoglobin) test is run, Pearce says. "This lab test is not typically ordered for elderly people, but it is the best way to get an accurate picture of the hemoglobin level," she says.
Because glucose sticks to red blood cells, even as they are dying, the HbA1C can provide an average hemoglobin level for a 90-day period, Pearce points out. While testing blood sugar prior to and after meals is important, the HbA1C is a better way to evaluate control of blood sugar, she says.
"If the result is less than 7, one HbA1C per year is enough. But if the result is above 7 or seems to be creeping up with each annual test, consider running the test every three months until it stabilizes or drops," Pearce adds.
Even with the HbA1C, patients need to monitor blood sugar daily, Thibodeau says. A post-meal blood sugar should be taken two hours after a meal, she says.
Other times, patients should monitor blood sugar are at bedtime, when they are ill, when they "feel funny," and when they wake up, Pearce says. The first test after waking up gives the patient a "fasting" blood sugar level, she adds.
Blood sugar monitoring not always is done as often as needed, Pearce contends. In fact, 16% of Type 1 patients never monitor blood sugar, and 20% of Type 2 patients never monitor blood sugar,1 she says. One reason is the cost of supplies, she explains.
"To save on supplies, have the patient monitor different times each day. One day, the patient monitors the fasting blood sugar; the next day, test blood sugar after a meal; and the next day, test a bedtime blood sugar." As long as the patient tests at different times each day, and as long as the patient is stable, once-a-day testing is sufficient, she adds.
Monitor the patient’s blood pressure as well, Pearce says. By lowering blood pressure from 140/90 to 130/85, the onset or progression of complications can be delayed, she explains.
Education is the key to making sure your patients are monitoring and controlling their diabetes, Pearce says. "Education enables the patient or family caregiver to become self-sufficient and able to make decisions," she says. The nurse should not automatically test the patient’s blood sugar or give an insulin injection, she explains. Instead, have the patient or family member do it while the nurse watches, she adds.
By watching patients inject themselves, the nurse can make sure that changes in vision or manual dexterity are not affecting the ability to inject insulin correctly, Pearce adds. "Also, look carefully at the patients’ log books where they list blood sugar levels," she suggests. "If the book is messy, blood-stained, and lists results in different ink colors, the patient is truly monitoring blood-sugar levels," she says. If, however, the log is neat, you might suspect that the patient is not monitoring on a regular basis, and just fills in the book prior to your visit, she suggests.
Ask patients to tell you how they addressed high or low blood-sugar readings, Pearce suggests. Staff need to check the patients’ ability to make decisions as well as perform the tests, she adds.
"It’s hard for elderly [patients] to recognize the signs of hypoglycemia, or low blood sugar, so make sure you give them cues in language they can understand," Pearce suggests. Use words such as silly, irritable, shaky, nervous, sweaty, or point out that vision changes, headaches, panic attacks, or any behavior change might indicate a need to check blood sugar, she says.
If the drop in blood sugar levels happens while sleeping, which it does about 50% of the time, the patient will wake up sweating or following a nightmare, Pearce explains. "I tell my patients to keep a small, about 4 ounces, box of apple juice, or three or four glucose tablets in a resealable baggie on their nightstand," she says. "We don’t recommend orange juice because it causes allergic reactions in many people," she explains.
"It’s harder for elderly patients to recognize hyperglycemia, or high blood sugar," Thibodeau says. "Hunger, thirst, frequent trips to the bathroom, dizziness, vision problems, and headaches are the most typical symptoms, but they vary from person to person," she explains. It is important to have the patient or caregiver note the symptoms that occur during both low and high blood-sugar episodes so they will recognize the pattern and be better able to administer insulin or glucose, she adds.
The most important thing to communicate to your diabetic patients is that diabetes is a progressive condition that continually changes, Pearce says. For this reason, it’s important to teach the patient to recognize signs of complications such as foot sores, nausea, diarrhea, redness, or swelling following an injury. "When the patient notices any changes, the physician should be called immediately," she adds.
Physicians are becoming more aware of the need to control the diabetes as well as treat the complications of diabetes, but a home health nurse can play an important role in the ongoing education of both physicians and their patients, Pearce suggests.
"Because we have the opportunity to observe the patients in their homes as they test their blood sugar and make decisions based on those test results, we can identify gaps in education and we can let the physician know exactly how the patients are doing," she says.
[For more information on diabetes and home health management of the disease, contact:
- Faith Thibodeau, MS, RD, LD, Diabetes Educator, Visiting Nurse Services, 15 Industrial Park Road, Saco, ME. Telephone: (207) 284-4566. Fax: (207) 282-4148. E-mail: [email protected].
- Linda C. Pearce, RN, C, BSM, Consultant, Diabetes Education Consulting, 2523 Black Cherry Lane, Blacksburg, VA 24060. Telephone: (540) 969-0246 E-mail: [email protected].
For more information about diabetes, as well as publications for health professionals, contact:
- The American Diabetes Association, 1701 N. Beauregard St., Alexandria, VA 22311. Telephone: (800) 342-2383 or (703) 549-1500. Web site: www.diabetes.org.]
Reference
1. Evans JM, Newton RW, Ruta DA, et al. Frequency of blood glucose monitoring in relation to glycemic control: Observational study with diabetes databases. BMJ 1999; 319:83-86.
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Types of Diabetes |
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There are two types of diabetes that occur, and it is necessary to know which type your patient has in order to properly manage the disease, says Linda C. Pearce, RN, C, BSN, a consultant with Diabetes Education Consulting in Blacksburg, VA. Type 1This is a disease in which the body does not produce any insulin, most often occurring in children and young adults. People with Type 1 diabetes must take daily insulin injections to stay alive. Type 1 diabetes accounts for 5% to 10% of diabetes. Type 2This is a metabolic disorder resulting from the body’s inability to make enough, or properly use, insulin. It is the most common form of the disease. Type 2 diabetes accounts for 90% to 95% of diabetes. Type 2 diabetes is nearing epidemic proportions, due to an increased number of older Americans and a greater prevalence of obesity and sedentary lifestyles. |
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