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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
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