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Diabetes Murray Calloway County Hospital Intranet Home

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					                                                        Nursing Policy and Procedure Manual
                                                                              Section IV-004
                                                                                       CORE
                                 Murray-Calloway County Hospital
                                  And Long Term Care Division

POLICY TITLE:
Diabetes: Teaching the Patient/Resident/Caregiver

POLICY STATEMENT:
The Center for Diabetes Management is responsible for teaching patients/residents/and/or their
caregivers how to give injections as well as evaluating their injection techniques. When Center for
Diabetes Management staff are not available, licensed nurses perform this task. Licensed nurses
reinforce education done by the Center for Diabetes Management.

Acute care patients may be discharged home with a referral to Home Care for continued education
and assessment of techniques. If the Home Care patient/caregiver is unable to learn appropriate
techniques, Home Care licensed staff notifies the physician for further orders.

PROCEDURE:
Supportive Data:
Education of the patient/resident with diabetes and/or family includes patient safety skills
recommended by the American Diabetes Association. These include:
 monitoring blood glucose,
 managing diet,
 knowing the different types and concentrations of insulin,
 preparing and giving self-injections of insulin,
 recognizing the signs and symptoms of hypoglycemia and hyperglycemia, and
 intervening appropriately to achieve glucose levels within an acceptable range.
Successful teaching is dependent on many factors, including the patient’s/resident’s/caregiver’s
readiness and ability to learn, level of knowledge and understanding of diabetes as well as the
patient’s/resident’s/caregiver’s physical condition. For these reasons a multidisciplinary approach
is essential. Patients are also encouraged to continue with outpatient diabetes education after
discharge.

The ability of a patient/resident with diabetes to learn how to administer injections depends in part
on the progress of the disease. Diabetes is a chronic condition that ultimately can cause loss of
vision and peripheral nerve sensation which may impact a patient’s/resident’s ability to self-
administer insulin injections. The nurse may need to adapt the teaching and/or recommend the
purchase of special equipment to the patient/resident or focus on educating family
members/primary caregivers.
Diabetes: Teaching the Patient/Resident/Caregiver          Nursing Policy and Procedure Manual
                                                                               Section IV-004a
Equipment:
Diabetes teaching literature:
Computer generated educational materials are available on the following diabetic topics:
      Adult:
       -Introduction to Diabetes Mellitus
       -Hyperglycemia/Hypoglycemia
       -Injecting One Insulin in Syringe
       -Injecting Two Insulins in One Syringe
       -Patient Safety Skills
       -What To Do If You Are Sick
       -Foot Care
       -How Do I Manage My Diabetes When I Get Home?
      Pediatrics:
       -Diabetes, Newly Diagnosed
       -Diabetes Type 1 - Poor Control
       -Hypoglycemia
       -Hyperglycemia
       -Patient Safety Skills
The following additional equipment may be needed:
- V.C.R. - with diabetic videotapes
- Supplies for insulin injection, if indicated
   - Vial(s) of insulin in correct concentration (U-100) and type(s)
   - Insulin syringe
           o Adult—1/2 inch needle with standard insulin barrel syringe
           o Pediatric—3/16 or 5/16 inch needle with half unit barrel syringe
- Supplies for blood glucose monitoring
- Antiseptic swabs
- Diabetes literature packet containing injection record


              STEPS                                                KEY POINTS

I.   General Teaching Guidelines                           Teaching is done primarily by the
                                                           diabetes educators. If not available,
     A. Provide the patient/resident with diabetic         clinical dietitians, RN’s, LPN’s,
        literature and video tapes for viewing.            nursing students, and externs may
        Include the caregiver whenever possible.           initiate and/or reinforce education.
     B. Develop individualized goals for the               Most patients/residents experience
        patient/resident based on present level            the grieving process when they re-
        of knowledge and readiness:                        ceive a diagnosis of diabetes.
Diabetes: Teaching the Patient/Resident/Caregiver         Nursing Policy and Procedure Manual
                                                                               Section IV-004b

               STEPS                                               KEY POINTS

          1. Move through the teaching                     Because of shock and/or disbelief,
             plan at the patient’s/resident’s/             explanations usually need to be
             caregiver’s own pace, utilizing               repeated many times. Assess for the
             appropriate teaching materials.               need for emotional and/or spiritual
          2. Update the nursing care plan as indicated.    support. Make referrals as
                                                           appropriate.
      C. Encourage the patient/resident/caregiver
         to participate in care as their knowledge
         and skill levels increase:

          1. Involve patient/resident/caregiver in:
             a. Blood glucose monitoring                   Have patient/resident/caregiver ob-
             b. Urine testing                              serve meal trays and see how the
             c. Planning menus for home                    meal plan is being carried out.
          2. Encourage patient/resident/                   Encourage patient/resident/caregiver
             caregiver to do additional                    to visit the hospital’s library; write
             reading and obtain additional                 out questions they might have, and
             outpatient education.                         give them the telephone number of
                                                           the Center for Diabetes: (270) 762-
                                                           1806.
      D. Assist the patient/resident/caregiver             Education includes timing of
          in keeping records of care including             insulin administration around meals.
          injection sites, time and date of                (See Diabetes: Care of Patient,
          injections and test results.                     Nursing Policy and Procedure
                                                           Manual Section III-012.)
II.   Teaching the Patient/Resident How
      to Give Insulin Injections
      A. Assess patient’s/resident’s/caregiver’s
          current level of knowledge.
      B. Have patient/resident/caregiver wash              Patient/resident must understand that
          hands while explaining the importance            aseptic or clean technique is required
          of hand-washing.                                 to perform injections safely.
      C. Provide patient/resident privacy.
      D. Show chart of injection sites and locate          Patient/resident/caregiver must learn
          each accessible site on patient’s/resident’s     correct sites for injecting insulin into
          body.                                            subcutaneous tissue. Observing
                                                           body parts allows the nurse to point
                                                           out areas that should be avoided such
                                                           as scars and bruises.
Diabetes: Teaching the Patient/Resident/Caregiver   Nursing Policy and Procedure Manual
                                                                        Section IV-004c

              STEPS                                        KEY POINTS

          1. Discuss the importance of rotating
             systematically.
          2. Provide patient/resident/              Patients/residents/caregivers are pro-
             caregiver with injection record        vided forms for recording the site of
             that (s)he can mark.                   injections in the diabetic literature
                                                    packet.
     E.   Allow patient/resident/caregiver to       Familiarity with aseptic technique
          manipulate syringe parts. Explain         in handling syringe ensures safe drug
          which parts must remain sterile and       administration.
          which can be touched.
     F.   Have patient/resident/caregiver           Concentration of insulin in units and
          compare syringe scale with insulin        the number of units marked on the

          label of concentration on insulin         syringe should match. For example,
          vial.                                     100 units syringe is used only with
                                                    U-100 insulin.
     G. Discuss patient’s/resident’s ordered        Dose in units is the number of units
        dose.                                       prepared in syringe.
     H. Demonstrate technique for mixing            After sitting, intermediate and long
        insulin within a vial by gently rolling     acting insulins form crystals on the
        bottle between your hands.                  bottom of vial. Mixing produces a
        Then allow patient/resident/caregiver       uniform solution. Shaking creates
        to mix vial. Explain to patient/            air bubbles.
        resident/caregiver that vial should
        never be shaken.
     I. Demonstrate and explain steps               Use simple step-by-step explanations
        used to prepare syringe:                    so patient/resident/caregiver can ask
                                                    questions at any time.
          1. Be sure to select syringe with         Insulin syringes have various needle
             appropriate length needle.             lengths. Shorter needles are used for
                                                    pediatric (3/15 and 5/16 inch) and
                                                    small, thin adult patients. The
                                                    standard insulin needle is ½ inch.
                                                    Overweight patients (BMI = 25-29.9)
                                                    and obese patients (BMI = over 30)
                                                    may also pose a problem. If the needle
                                                    is too short, insulin will pool which
                                                    causes poor absorption and may cause
                                                    infection/abscess at site.
                                                    Consult doctor when caring for an
                                                    obese patient.
Diabetes: Teaching the Patient/Resident/Caregiver         Nursing Policy and Procedure Manual
                                                                              Section IV-004d

              STEPS                                              KEY POINTS

          2. Wipe off top of vial with alcohol swab.      Label vial with date/time opened.
          3. Remove needle cover.
          4. Pull plunger out to the same number
             of units to be removed from vial.
          5. Push needle slowly into rubber on
             top of vial.
          6. Push plunger to push air into bottle.        This prevents a vacuum in vial.
          7. Hold vial and syringe together;
             turn both upside down. Try to hold
             vial between thumb and forefinger,
             and let syringe rest against palm.
          8. Slowly pull back on plunger,                 Be sure needle stays in the fluid in
             withdrawing the number of units of           vial.
             insulin to be given.
          9. Check for air bubbles in syringe.            Small bubbles are not harmful but
                                                          take up space, and the correct
                                                          amount of insulin may not be prepared.
          10. If bubbles are seen, tap side of syringe
              barrel sharply with middle finger while
              holding syringe upright. When bubbles
              rise to the top of the syringe, pull back
              slightly on plunger and then push it
              back to the correct number of units,
              ejecting the air.
          11. Check to be sure the correct amount         Both the nurse and the patient/
              of insulin is in the syringe, and no air    resident/caregiver perform this
              bubbles are present                         double-check.
          12. Remove syringe from vial by pulling
              it straight out.
          13. Put cap or sheath back without
              touching needle.
     J.   Have patient/resident/caregiver                 Give insulin in 2 separate injections
          locate previously chosen injection site.        to patients who require more than
                                                          50 units at one time. This avoids
                                                          pooling of insulin under the skin.
     K. Prepare injection site and administer             Nurse’s instructions during demon-
        insulin while explaining each step slowly.        stration include principles for
        Encourage questions.                              minimizing pain, inserting needle
                                                          correctly, and maintaining asepsis.
          1. Clean site with alcohol swab.
          2. Take cover or sheath off needle.
Diabetes: Teaching the Patient/Resident/Caregiver         Nursing Policy and Procedure Manual
                                                                              Section IV-004e

                STEPS                                            KEY POINTS

            3. Hold syringe as you would a pencil.
            4. Grasp injection site between thumb         To inject arm, press back of upper
               and fingers of free hand.                  arm against back of chair. “Roll”
                                                          arm down to push up skin.
            5. With quick jab, insert needle into         Small children and thin adults should
               cleaned area at an angle of approxi-       also inject at a 90 degree angle, but
               mately 90 degrees.                         use a shorter needle.
            6. Using dominant hand, gently                Partial insertion of needle may result
                insert needle to hub.                     in insulin being injected into intra-
                                                          dermal area. Routine aspiration to
                                                          check for blood is no longer
                                                          necessary.
            7. Stabilize syringe by grasping with         Remember: with Lantus, hold
                non-dominant hand while using             plunger in for 3 seconds before
                dominant hand to push plunger to          pulling needle out.
                administer insulin.
            8. Gently put alcohol swab over               Do not massage injection sites
                injection site and pull needle            following injections. Site massage
                out quickly.                              induces more rapid absorption and
            9. Briefly hold alcohol swab                  action from a dose of insulin.
                over site.
       L.   Discard uncapped needle and syringe           Follow Nursing Policy and Proce-
            in an appropriate container.                  dure Manual, Section IX-3, “Ex-
                                                          posure Control Plan”.
       M. Have patient/resident/caregiver mark
          on injection record injection site.
       N. Have patient/resident/caregiver
          wash hands.
       O. Evaluate patient’s/resident’s/                  Remember: Patients/residents/care-
          caregiver’s technique. Do                       givers who have been giving injections
          further teaching if needed.                     for years may not be using correct
                                                          techniques and may benefit from
                                                          review and evaluation of technique.

III.   Teaching the Patient/Resident/Caregiver
       Self Blood Glucose Monitoring Using a
       Portable Blood Glucose Meter
       A. If Center for Diabetes staff are not
            available for diabetic teaching:
            1. Assess patient’s/resident’s/caregiver’s    Information gathered helps the nurse
               understanding and ability to handle skin   develop an individualized teaching
Diabetes: Teaching the Patient/Resident/Caregiver          Nursing Policy and Procedure Manual
                                                                               Section IV-004f


            STEPS                                            KEY POINTS
______________________________________________________________________________
           puncturing devices and portable             plan.
           blood glucose meters.
        2. Determine if the patient/resident/caregiver
           realizes the importance of glucose
           monitoring and can accurately perform
           the test.
        3. If patient/resident/caregiver is unsure or
           needs reinforcement, refer to manufac-
           turer’s instructions for glucometer.
        4. Offer encouragement and assure patient/
           resident/caregiver that they will
           have other opportunities to practice with
           help from the nursing staff.
        5. Provide information on where the patient/
           resident/caregiver can obtain needed
           supplies following discharge.

Documentation:
Documentation is done in PCS or on forms appropriate to the care setting.

Reference:
A Core Curriculum for Diabetes Education, 4th Edition, published by The American Association of
Diabetes Educators & The AADE Education and Research Foundation, 2001.

Approvals:
Nursing Policy and Procedure Committee                                      Date: 09/2008
Nursing Leadership Council                                                  Date: 09/2008
V/P Nursing Services                                                        Date:

Original:    03/1996
Revised:     11/1999, 12/2002, 09/2005, 08/2006, 09/2008