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Nursing Study Guide
TARGET Diabetes Nursing Study Guide
Published: 01/2006
Copyright 2006 by MaineHealth. All rights reserved. The material contained in this publication may be
displayed, copied, distributed or downloaded for personal or noncommercial uses, provided such materials
are not altered or modified and a reference to MaineHealth is provided.
Inquiries regarding specific permissions should be directed to:
Kristina M. Scrutchfield
TARGET Diabetes Program Manager
MaineHealth
465 Congress Street, Suite 301
Portland, ME 04101
Phone: (207) 541-7534
Fax: (207) 541-7540
Email: scrutk@mmc.org
This publication and the materials and information contained herein have been produced for informational
purposes as a service to patients, their families, and the general public and are provided “as is” without a
warranty of any kind, either express or implied. MaineHealth shall not be liable for direct, indirect, special,
incidental or consequential damages related to the user’s decision to use this publication or any material or
information herein.
TARGET Diabetes Nursing Study Guide
1
Table of Contents
I. INTRODUCTION...........................................................................................I-1
A. Contributors ....................................................................................................................... I-1
B. Objectives........................................................................................................................... I-2
C. What is the TARGET Diabetes Program?........................................................................ I-3
D. What is MaineHealth?........................................................................................................ I-3
II. DIABETES ...................................................................................................II-1
A. What is Diabetes?............................................................................................................. II-1
1. Diagnosis .................................................................................................................................... II-2
2. Types of Diabetes...................................................................................................................... II-2
3. Risk Factors ............................................................................................................................... II-3
III. CHRONIC COMPLICATIONS.....................................................................III-1
A. How to Prevent Complications....................................................................................... III-1
IV. TREATMENT ............................................................................................. IV-1
A. Meal Planning...................................................................................................................IV-1
B. Physical Activity ..............................................................................................................IV-2
1. Problem-Solving for Barriers to Activity.................................................................................IV-4
2. Testing Blood Glucose and Activity .......................................................................................IV-5
3. Hypoglycemia............................................................................................................................IV-5
C. Methods Used to Monitor Diabetes Control..................................................................IV-6
1. Tests for Glycemia ...................................................................................................................IV-6
2. Self Monitoring of Blood Glucose...........................................................................................IV-7
D. Oral Medication Therapy...............................................................................................IV-11
E. Insulin Basics.................................................................................................................IV-12
1. Type..........................................................................................................................................IV-12
2. Concentration..........................................................................................................................IV-13
3. Purity ........................................................................................................................................IV-13
4. Sources....................................................................................................................................IV-13
F. Insulin Pumps ................................................................................................................IV-13
G. Insulin Guidelines and Pens.........................................................................................IV-14
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H. Incretin Mimetics............................................................................................................IV-14
V. ACUTE COMPLICATIONS ......................................................................... V-1
A. Hypoglycemia (Low Blood Glucose) ..............................................................................V-1
1. Symptoms................................................................................................................................... V-1
2. Causes ........................................................................................................................................ V-1
3. Treatment ................................................................................................................................... V-2
4. Prevention................................................................................................................................... V-3
5. Medic-Alert Identification .......................................................................................................... V-3
B. Hyperglycemia (High Blood Glucose) ............................................................................V-3
1. Symptoms................................................................................................................................... V-3
2. Causes ........................................................................................................................................ V-4
3. Treatment ................................................................................................................................... V-4
4. Prevention................................................................................................................................... V-4
C. Diabetic Ketoacidosis (DKA) ...........................................................................................V-4
1. Symptoms................................................................................................................................... V-5
2. Causes ........................................................................................................................................ V-5
3. Treatment ................................................................................................................................... V-5
4. Prevention................................................................................................................................... V-6
D. Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS)..................................V-6
1. Symptoms................................................................................................................................... V-6
2. Causes ........................................................................................................................................ V-6
3. Treatment ................................................................................................................................... V-6
4. Prevention................................................................................................................................... V-7
E. Sick Day Guidelines .........................................................................................................V-7
1. What Patients Should Do When Ill:......................................................................................... V-7
2. Prevention................................................................................................................................... V-8
VI. STRESS AND DIABETES ......................................................................... VI-1
A. Sources of Stress ............................................................................................................VI-1
B. Getting a Handle on Stress.............................................................................................VI-1
C. Depression and Diabetes................................................................................................VI-2
D. Diabetes and the Family..................................................................................................VI-3
VII. THE CHANGE PROCESS................................................................... VII-1
A. Goal Setting Example.....................................................................................................VII-1
B. Behavior Change Goals .................................................................................................VII-2
1. Long-Term Goals.....................................................................................................................VII-2
2. Short-Term Goals....................................................................................................................VII-3
3. Acceptable Goals ....................................................................................................................VII-4
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C. Diabetes Educators ........................................................................................................VII-4
VIII. DIABETES AND PREGNANCY ......................................................... VIII-1
A. Preconception Visit ..............................................................................................VIII-1
IX. TESTING AND COMPETENCIES.............................................................. IX-1
A. Diabetes Study Guide Pretest/Post test ........................................................................IX-1
B. Diabetes Study Guide Pretest/Post test (Answer Key) ................................................IX-5
C. Insulin Injection Competency.........................................................................................IX-9
D. Hypoglycemia Competency..........................................................................................IX-10
E. Glucometer Competency ..............................................................................................IX-11
F. Monofilament Competency...........................................................................................IX-12
G. Insulin Pen Competency ...............................................................................................IX-13
X. APPENDIX .................................................................................................. X-1
A. Diabetes Summary ...........................................................................................................X-1
B. Pre-Diabetes......................................................................................................................X-1
C. References.........................................................................................................................X-1
D. More Information...............................................................................................................X-1
XI. END NOTES............................................................................................... XI-1
TARGET Diabetes Nursing Study Guide
I-1
I. INTRODUCTION
A. Contributors
We would like to thank the following individuals for their interest, input, and support in
developing this study guide:
Stephan Babirak, MD The Maine Center for Diabetes Sandy Barth, RN, BSN, CDE Miles Memorial Hospital Kathleen Beers, RN, BSN, CDE Mercy Hospital Pauline A. Bergeron Flood, BS MaineHealth
Donna Bolstridge, RN, BSN Home Health Visiting Nurses of Southern Maine Kay Mullin, RD, LD, CDE The Maine Center for Diabetes Bonnie Quint, RN, BSN, CDE Houlton Regional Hospital Kris Scrutchfield, RT(R)(CV) MaineHealth Pat Watson, RD, MS, CDE Stephens Memorial Hospital Cindy Young, RN, C, CDE The Maine Center for Diabetes Susan Young, RN, BSN, CDE Blue Hill Memorial Hospital Written and Edited by: Tracy Callahan, RN, MSN, CDE The Maine Center for Diabetes
Laura Gordon, RN, BSN, CDE Maine Medical Center – Physicians Health Organization
Mary McDonough, RN Maine Medical Center Family Practice Center TARGET Diabetes Nursing Study Guide
I-2
B. Objectives
This study guide was developed by the TARGET Diabetes Program at MaineHealth to
provide a basic overview of diabetes for registered nurses, licensed practical nurses,
medical assistants, and any other clinical person who feels they could benefit. Included is
a pretest & posttest as well as competencies for:
• Injecting insulin
• Treating hypoglycemia
• Glucometer instruction
• Use of insulin pens
• Monofilament testing
By reading this study guide and completing the post test and competencies, you should be
able to:
• Describe generally what diabetes is, how it is diagnosed, who is at risk, and how it
is treated.
• State the symptoms, causes, treatment, and prevention of hypoglycemia,
hyperglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic nonketotic
syndrome.
• Identify the potential chronic complications that can occur due to diabetes.
• State how patients should care for themselves in general as well as when ill, under
stress, and during pregnancy.
Once you have completed reading this study guide, go to:
http://www.surveymonkey.com/s.asp?A=68915169E36695
to do a brief evaluation of this learning tool.
Feel free to copy and share sections with your patients such as the blood glucose log,
self-care action plan, activity suggestions, goal setting, sick day foods, insulin pen use,
and guidelines for the use of insulin.
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C. What is the TARGET Diabetes Program?
The TARGET Diabetes Program is a program offered by MaineHealth to improve care
and outcomes for people with diabetes. The goals of the program are to:
• Promote effective diabetes patient education and self-management skills for
Maine adults and their families.
• Promote public awareness of diabetes as a common, serious, and preventable
medical illness.
• Support doctors and nurses in providing high quality care to people with diabetes.
• Promote healthy lifestyles and activities that help prevent diabetes and its’
complications.
D. What is MaineHealth?
MaineHealth is a nonprofit health care system that includes Maine Medical Center, eight
community hospitals, and other health care organizations in the ten counties of southern
central and western Maine. The mission of MaineHealth is “working together so our
communities are the healthiest in America.” In addition to providing the highest quality
medical care possible, MaineHealth actively supports community health improvement
through programs like TARGET Diabetes.
For more information about diabetes, the TARGET Diabetes Program, and MaineHealth,
please check out our website at www.mainehealth.org and click on Health Information
then click the Diabetes link or you can contact:
Kristina M. Scrutchfield, RT(R)(CV)
TARGET Diabetes Program Manager
MaineHealth
465 Congress St., Suite 301
Portland, ME 04101
Phone: (207) 541-7534
e-mail: scrutk@mmc.org
TARGET Diabetes Nursing Study Guide
II-1
II. DIABETES
A. What is Diabetes?
“Diabetes Mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action, or
both”1
The pancreas has two functions. It secretes pancreatic juices which help us to digest our
foods and it secretes hormones that control body processes. Insulin is a hormone
produced by the beta cells in the pancreas whose chief function is to help the body’s cells
take in blood glucose. The carbohydrate in foods we eat is largely broken down into
glucose. Glucose is absorbed into the bloodstream and delivered to the cells where it is
used for energy or it is stored for energy use later.
Blood glucose levels rise immediately after eating. In response to this rise in glucose, the
pancreas secretes insulin. The cells have receptor sites for insulin. Insulin acts like a key
to the cell. Once insulin attaches, it opens the cell so that glucose can enter. By doing
so, the cell receives energy and the glucose levels in the bloodstream decrease. Diabetes
is caused by the body’s failure to make insulin or properly use the insulin it does make.
The symptoms exhibited by patients with diabetes are connected to the body’s attempt to
correct what it senses as abnormal, in this instance, hyperglycemia. The following are
the “classic symptoms of diabetes”:
• Polyuria – The kidneys are working extra hard to remove the excess
glucose from the bloodstream through the urine.
• Polydipsia – When the body releases extra glucose into the urine, it pulls
water with it, thus causing dehydration and the symptom of increased
thirst. Drinking more also allows the kidneys to filter more glucose.
• Polyphagia – If cells are not receiving enough glucose for normal
functioning they end up hungry! This is also why patients report fatigue,
weakness and weight loss.
• Blurred vision – Changes in vision frequently occur. This change is due
to extra glucose in the bloodstream. When glucose levels are high,
glucose pulls water with it. The combination causes swelling in the lens
and a distortion in the vision.
TARGET Diabetes Nursing Study Guide
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1. Diagnosis
Diagnosis for diabetes may be done through the following methods:
• Fasting Plasma Glucose – A blood sample is taken 10-12 hours after the
previous meal (generally first thing in the morning before breakfast). Values
> 126 are diagnostic for diabetes.
• Casual Plasma Glucose Test – A random blood glucose level taken any time of
day regardless of when the last meal occurred. Values > 200 mg/dl with “classic”
symptoms are diagnostic for diabetes.
• Oral Glucose Tolerance Test (OGTT) – After a 10-12 hour fast, a blood glucose
sample is taken. A 75 gm glucose solution is given to the patient. After two
hours, another blood glucose sample is taken. Values > 200 mg/dl are diagnostic
for diabetes.
• Pre-Diabetes – Diagnosis for a condition preceding diabetes, known as Pre-
Diabetes is determined by:
-- Fasting Plasma Glucose (see above) – Reveals blood glucose level
between 100-125 mg/dl.
-- Oral Glucose Tolerance Test (OGTT) (see above) – Blood glucose levels
> 140 mg/dl but < 200 mg/dl.
All tests need to be repeated to confirm diagnosis.2
2. Types of Diabetes
The two most common types of diabetes are type 1 and type 2. In type 1 diabetes, the
pancreas makes little or no insulin. In fact, within 10 years most persons with type 1
diabetes will no longer be making any insulin at all. People with type 1 diabetes are
prone to developing ketosis which is discussed at length in the ‘acute complications’
section. People with type 1 diabetes need insulin shots in order to live. Type 1 diabetes
can begin at any age, but usually occurs before age 30.
In type 2 diabetes, the pancreas may produce more insulin than usual, but the cells are
unable to use it. Food is broken down in the normal way; however, three areas important
to how we process the glucose supplied by our food are affected. The first is the liver. It
normally stores excess glucose for when our bodies need it, such as during exercise or
missed meals. With type 2 diabetes, the liver becomes overactive due to hormones and
spills glucose into the bloodstream. Second are the cells themselves. Typically the cells
should grab onto the insulin, open up and allow the glucose in. With diabetes, the cells
are resistant and unable to use the insulin efficiently. This is due in large part to lifestyle
TARGET Diabetes Nursing Study Guide
II-3
issues such as obesity which creates fatter cells, as well as inactivity, and genetics. This
is referred to as ‘insulin resistance’. Third, we now know that the beta cells of the
pancreas decline over the years. So, the longer a person lives with type 2 diabetes, the
increased chance he/she has that their body will need pharmacological help to do the
same work it does now. Glucose builds up in the bloodstream instead of entering the
cells for these reasons.
Changes in lifestyle are the most effective way to deal with type 2 diabetes. Regardless if
this is a new diagnosis or a patient who has had it for many years, meal planning and
exercise are the key tools used to control blood glucose levels. The onset for type 2
diabetes is more common over the age of 40 but can occur at any age. In fact, we are
now seeing it in the pediatric population.
Gestational diabetes occurs during pregnancy. The hormones released during
pregnancy cause the mother to develop ‘insulin resistance’, similar to type 2 diabetes.
This usually resolves after delivery of the baby. It is however, a risk factor for
developing type 2 diabetes in the future.
3. Risk Factors
Type 1 diabetes is an auto-immune disease. This means the body begins to recognize
the beta cells (the insulin producing cells) in the pancreas as foreign substances and
begins to develop antibodies to them, thus eventually destroying them and their ability to
produce insulin. There are several theories as to the actual pathology of type 1 diabetes,
however the most common idea is that people have the genetic pre-disposition to
developing it. The person comes into contact with an environmental or genetic trigger
(virus) and this begins the destruction of the beta cells.
Type 2 diabetes results from a combination of risk factors. Genetics and ethnic
background (Native Americans, Hispanic Americans, and African Americans have a
higher incidence of type 2 diabetes) predispose patients to a greater risk. Other factors
are being overweight, > 30 years of age, having a baby >9 pounds, and having a history
of gestational diabetes or prediabetes.
Stress, illness or surgery, and certain medications such as steroids, can aggravate diabetes
and make it more difficult to control. Chronic pancreatitis and pancreatic cancer
resulting in the partial or total removal of the pancreas can also lead to diabetes.
Diabetes is a serious, lifelong condition. The majority of what it takes to control blood
glucose levels is done by the patient (> 99%).3 Some days glucose levels are great and
the next day not so great; there are degrees of control. It is important to communicate
that diabetes never goes away! Living with diabetes is a lot of work. New skills are
required to learn about the disease and what steps can be taken to control it. Changing
lifestyle habits by becoming more active, learning how to eat healthy and to control stress
will help a person live a full, healthy and productive life.
TARGET Diabetes Nursing Study Guide
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III. Chronic Complications
Diabetes can lead to serious, long-term complications. Eyes, feet, kidneys, nerves, heart and blood
vessels, as well as other parts of the body can be affected. The primary contributors to the
development of complications are: 1) high blood glucose levels; 2) high blood pressure; and
3) high blood fats. The potential results of these three factors are: 1) diminished or blocked blood
flow; 2) damage to the blood vessels; and 3) nerve destruction. Below are listed potential
complications:
• Heart & Blood Vessel Disease
Heart attack
Stroke
Peripheral Vascular Disease
Note: Cardiovascular Disease is the major cause of mortality for individuals with diabetes. It
is also a major contributor to morbidity and the direct and indirect costs of diabetes.
• Eye Disease
Retinopathy
Cataracts
Glaucoma
• Nephropathy
Kidney disease – unable to excrete urine by the kidneys.
• Neuropathy
Sensory
Burning, numbness, poor coordination in feet, legs, hands and arms
Note: Footcare tip sheet is located in the back of this section.
Autonomic
Damage to organs that function without conscious thought:
stomach, heart, blood pressure, intestines/bowels, bladder, skin & sex
organs
• Other
Mouth – tooth decay, thickening of blood vessels, gum disease
Decreased immune system functioning
Skin – increased infections
A. How to Prevent Complications
The Diabetes Control and Complications Trial (DCCT) is a clinical study that was conducted from
1983 to 1993 by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
TARGET Diabetes Nursing Study Guide
III-2
The study showed that keeping blood glucose levels as close to normal as possible slows the onset
and progression of eye, kidney, and nerve diseases caused by diabetes. In fact, it demonstrated
that any sustained lowering of blood glucose helps, even if the person has a history of poor control.
Note: DCCT article is in the back of this section.
At each visit ask patients about any new or continuing symptoms they may be having such as pain
or lack of sensation in their extremities, changes in vision, frequent infections, slow healing of cuts
and sores, fatigue, shortness of breath, or chest pain. Encourage your patients to see a provider to
evaluate sores or symptoms as soon as they arise. DO NOT WAIT!!! Early detection is the key to
prevention.
The American Diabetes Association (ADA) publishes Standards of Care each year.
This is a list of what each person with diabetes needs to do in an effort to prevent complications.
The ADA provides guidelines for lab tests with corresponding “acceptable levels” as well as
patient directed actions. These guidelines help providers and patients focus on early detection and
prevention of complications. Guidelines are also provided for the treatment of high blood
pressure, high blood fats, and high blood glucose levels. Become familiar with these guidelines by
visiting the ADA website at www.diabetes.org. Share what you learn with your patients since, as
previously stated, it is estimated that > 99% of care provided to a person with diabetes, they
provide themselves.
General guidelines are:
• Hemoglobin A1c every 3-6 months
• Weight every visit (also should monitor at home)
• Blood Pressure check every visit
• Foot Check every visit (patient to check feet at home daily)
• Fasting Lipid Profile yearly
• Albumin/Creatinine Ratio yearly
• Flu Shot yearly
• Dentist yearly (brush & floss daily)
• Pneumovax
• Aspirin Therapy (unless contraindicated)
Note: Current year guidelines and monofilament information are in the back of this section.
The Bottom Line:
• Control Blood Glucose Levels!
• Control Blood Pressure!
• Control Blood Fats!
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Risk Factor Goal Frequency Why is it important?
Blood Pressure Less than 130/80 Every visit High blood pressure can cause kidney
damage and strokes.
Hemoglobin A1c Less than 7% Every 3 months Checks for control of blood glucose
levels over the past 2-3 months.
Low-Density Lipids
(LDL)
Less that 100 mg/dl
(If Cardiovascular Disease is
noted, less than 70 mg/dl is
optional)
Yearly
(more often if
needed to achieve
goal)
Checks for “bad” cholesterol. High LDL
can cause heart disease and strokes.
High-Density Lipids
(HDL)
Greater than 40 mg/dl
for men
Greater than 50 mg/dl
for women
Yearly
Checks for “good” cholesterol. Helps
keep “bad” cholesterol from building up
in the arteries.
Triglycerides Less than 150 mg/dl Yearly
A form of fat in your blood that can
raise your risk of heart disease. Value
can be elevated if the blood glucose
level is out of control.
Cholesterol Less than 200 mg/dl Yearly Used to estimate your risk of
developing heart disease.
Urine
Albumin/Creatinine
Ratio
Less than 30 ugALB/mgCR Yearly Checks for protein in urine, a sign of
early kidney damage.
Aspirin For patients over 40 yrs old
Each Day
(unless otherwise
indicated)
Prevents cardiovascular events.
Comprehensive Foot
Exam Healthy feet Yearly
Checks circulation, nerves, and skin. It
can prevent amputations.
*Patients are also encouraged to do a
foot check each day at home.
Dilated Eye Exam No retinal changes Yearly Checks for eye damage from diabetes,
can prevent blindness.
Influenza Flu shot Yearly Prevents a more severe form of the flu.
Pneumonia Pneumovax vaccine Discuss with
your doctor Prevents pneumonia.
BMI
(Body Mass Index) Less than 25 Every visit
Body Mass Index is a measure of weight
compared to height which relates to the
amount of body fat a person has.
Smoking Cessation
To quit smoking
The Maine Tobacco Helpline:
1-800-207-1230
Discuss at every
visit. Decreases premature death.
Teeth Cleaning and exam Every 6 months Prevents tooth and gum disease.
American Diabetes Association
Guidelines to Prevent
Complications from Diabetes
TARGET Diabetes Nursing Study Guide
III-4
Take Care of Your Feet for a Lifetime
Take care of your diabetes.
• Work with your health care team to keep your blood sugar within a good range.
Check your feet every day.
• Look at your bare feet everyday for cuts, blisters, red spots and swelling.
• Use a mirror to check the bottoms of your feet or ask a family member for help if you
have trouble seeing.
Wash your feet every day.
• Wash your feet in warm, not hot, water everyday.
• Dry your feet well. Be sure to dry between the toes.
Keep the skin soft and smooth.
• Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between
your toes.
Smooth corns and calluses gently.
• Use a pumice stone to smooth corns and calluses.
• Don’t cut corns or calluses yourself.
Trim your toenails each week or when needed.
• Trim your toenails straight across and tile the edges with an emery board or nail file.
• Trim after bathing when the nails are softer.
• Don’t cut into the corners of the nails.
Wear shoes and socks at all times.
• Never walk barefoot.
• Wear comfortable shoes that fit well and protect your feet.
• Stop wearing shoes that cause irritations.
• Feel inside your shoes before putting them on each time to make sure the lining is
smooth and there are no objects inside.
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Protect your feet from hot and cold.
• Wear shoes at the beach or on hot pavement.
• Wear socks at night if your feet get cold.
Keep the blood flowing to your feet.
• Put your feet up when sitting.
• Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day.
• Don’t cross your legs for long periods of time.
Be more active.
• Plan your physical activity program with your doctor.
Check with your doctor.
• Have your doctor check your bare feet and find out whether you are likely to have
serious foot problems. Remember that you may not feel the pain of an injury
• Call your doctor right away if a cut, sore blister, or bruise on your foot does not begin
to heal after one day.
• Follow your doctor’s advice about foot care.
Get started now.
• Set a time every day to check your feet.
• Begin taking good care of your feet today!
TARGET Diabetes Nursing Study Guide
III-6
Date:_________________
Patient name:______________________________________________ D.O.B._______________
Physician:___________________________________________ Diabetes Type : 1 2 (circle one)
Diabetes complications: ○ Peripheral neuropathy ○ Amputation: _________________ ○ Nephropathy
Smoker? Y N
1) Foot evaluation:
Fill in blanks with “Y” or “N” and indicate “Right” or “Left” foot Right Foot Left Foot
Is there a current ulcer or history of a foot ulcer?
Are there any changes in the foot since the last evaluation?
If yes, circle type of change: swelling / abnormal shape / elevated skin temp
Are there any deformities of the toes?
Are the toenails thick, too long, ingrown, or infected with fungal dx?
Is there any evidence of muscle weakness or foot drop?
Are the pulses present? Circle : posterior tibial / dorsalis pedis
Does the patient have properly fitting footwear?
Does the patient demonstrate appropriate foot care?
4) Risk categorization
Low risk includes all of the following: no amputation, no prior foot ulcer, no deformity, pedal pulse
present, intact protective sensation
High risk includes one or more of the following: prior amputation, history of foot ulcer, foot
deformity, absent pedal pulses, loss of protective sensation
5) Management
Referral made to: □ Podiatrist □ Vascular surgeon □ Foot surgeon □ Orthotist □ Vascular lab
□ Diabetes educator □ Endocrinologist □ Rehab specialist □ Other:__________________
Footwear recommended: □ None □ Athletic shoes □ Inserts □ Custom shoes □ Depth shoes
If smoker: □ cessation counseling provided □ referred to cessation counselor □ cessation meds prescribed
Schedule follow up foot exam in ____________ (mos)
Note: High risk patients should have foot exam at every visit. (Adapted from “Feet Can Last a Lifetime”(NDEP))
3) Foot assessment
Measure, draw in, and label
patient’s skin condition, using the
key below and foot diagram at left.
C= callus R= redness
U = ulcer S = swelling
PU= pre-ulcer W = warmth
F= fissue D= dryness
M= maceration
2) Sensory Foot Exam
Label sensory level with "+" in the
five circled areas of the foot if
patient can feel the monofilament
and "-" if they cannot. See nest
page or instructions on
monofilament use.
TARGET Diabetes Comprehensive Foot Exam
TARGET Diabetes Nursing Study Guide
III-7
Use of the Monofilament
How the monofilament works:
1) The filament applies 10 grams of pressure to a small point on the skin.
2) The filament is calibrated to bend when the 10 grams of force has been applied.
3) If the patient does not feel the monofilament when you apply pressure to bend it, sensation loss has
occurred in that area.
Who should the monofilament be used with?
• All patients with diabetes should have a filament test done at least annually.
• The American Diabetes Association (ADA) and the Bureau of Primary Health Care’s (BPHC)
Lower Extremities Amputation Program (LEAP) recommend visual foot
exams/inspections at each visit.
• You may request a supply of up to 50 free monofilaments by filling out the Free
Monofilament Form at: http://bphc.hrsa.gov/leap/ordering_leap_filaments.htm
How to use the monofilament
1) Show monofilament to patient. Demonstrate that it does not hurt.
Touch their hand / arm with monofilament.
2) Have patient turn head, close eyes, or look at the ceiling.
3) Ask patient to inform you when they feel the monofilament touching their foot.
4) Hold monofilament perpendicular to the skin and use 3 second sequence
a) touch the skin at the areas indicated on the adjacent diagram
b) filament bends
c) lift from the skin
5) Do not use rapid movement
a) Use in random sequence
b) If client does not say yes when a certain area is touched, continue in your
sequence. After you have completed, return to the area assessed as poor and
repeat the test.
Care of a non-disposable (durable) monofilament
1) The filament will last indefinitely if returned to its plastic case.
2) Cleaning the filament should be done between patients using sodium hypochlorite (household
bleach 1:10).
Education plays a major role in preventing amputations and serious problems with feet and legs!!!!!
To obtain a copy of the TARGET Diabetes provider foot exam worksheet or a foot check reminder
poster (compliments of the Maine Diabetes Control Program) for your waiting room, see the TARGET
Diabetes Program information on the MaineHealth website at www.mainehealth.org.
TARGET Diabetes Nursing Study Guide
IV-1
IV. TREATMENT
It is important to note here that hyperglycemia can prevent people from being motivated
to care for themselves. Lowering glucose levels with the help of oral medications or
insulin initially can get them feeling better faster and thus more motivated to begin and
maintain an exercise program, healthy eating habits, self monitoring of blood glucose
levels, taking prescribed medications, and other self-care activities.
A. Meal Planning
What people eat affects their overall health; including their weight, blood glucose control
and lipid profile. People who have diabetes are still regular people with normal
nutritional needs. A healthy eating diet that promotes normal growth and development
and meets all the nutrient needs remains the basis of the diet. However, because of the
need for good blood glucose control as well as fat control, additional dietary principles
need to be understood. Understanding one’s own eating choices and behaviors is crucial
to learning a healthy eating pattern for people with diabetes.
The major nutrients in food are: carbohydrates, proteins, fats, vitamins, minerals, and
water. There are three energy yielding nutrients: carbohydrates, proteins, and fats. The
body needs all of these in different amounts for good nutrition. One hundred percent of
carbohydrates breakdown to glucose; 50% of protein and less than 10% of fat are
converted to glucose.4
Glucose is the body’s main energy source and therefore the majority of the calories we
need to eat come from carbohydrates; approximately 45-65%.5 Insulin allows glucose to
enter into the muscle cell where it is used for energy. Balancing food, exercise, and
diabetes medication is essential for good diabetes control. Individuals need to pay close
attention to the amounts and timing of the foods they eat that are high in carbohydrates
since these have the greatest affect on blood glucose levels. A healthy eating plan needs
to be promoted to help with normal nutritional needs including normal growth and
development as well as weight control and heart health.
In type 1 diabetes injected insulin needs to be balanced with food. Since the person does
not make any insulin, blood glucose levels can rise rapidly if they do not have enough
insulin to cover a meal. With type 2 diabetes the ability to get glucose into the cells
slows down over time (insulin resistance) and the pancreas decreases its production of
insulin, often due to age, genetics, or weight gain.
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To prevent the body from becoming overwhelmed with glucose resulting in
hyperglycemia, there are a few basic guidelines you can teach your patients:
• Limit food portions at each meal or snack
• Divide food into 3 evenly spaced meals
• Aim for consistency in meal times
• Avoid skipping and/or delaying meals
• Consume mostly calorie free beverages
• Include foods from all food groups everyday
Tips to control portion sizes:
• Use a smaller plate
• Put utensils down between bites
• Encourage mealtime conversation
• Do not return for seconds
• Weigh & measure foods to learn appropriate serving sizes
Suggested visual teaching method for patients:
Demonstrate to patients how to divide their plate into acceptable portions. For
lunch and dinner divide the plate into ¼ carbohydrate, ¼ protein, and ½
vegetable. Breakfast is a bit more of a challenge since most of the choices are
carbohydrates. Therefore, encourage less juices and the addition of protein and
fiber (e.g. whole wheat toast with peanut butter, toasted almonds on cereal) which
helps to regulate blood glucose.
A dietitian can help patients to understand how their favorite foods can be worked into
their meal plan.
B. Physical Activity
Physical activity of any kind will help to lower blood glucose levels. Activity moves
glucose into cells, increases the sensitivity of cells to insulin, and increases the absorption
rate of insulin. All patients with diabetes should be encouraged to be as active as
possible. In addition to lowering blood glucose, physical activity helps to:
• Increase bone density and prevent osteoporosis
• Increase metabolism
• Control weight
• Relieve stress
• Boost mood, promote sleep
• Improve flexibility, joint range of motion & balance
• Improve muscle tone
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• Improve reflexes to decrease falls
• Improve cardiovascular health
• Create a sense of community or feeling of belonging
• Provide a sense of well-being
• Lower or control blood pressure
• Lower triglycerides “bad” cholesterol
• Raise HDL “good” cholesterol
The goal for everyone is to be active at least 30 minutes per day or more. During
exercise people should be able to talk in short sentences but not necessarily sing. Patients
should be encouraged to talk with their physician before starting an exercise program to
be sure the activity they wish to participate in will be safe for them. Patient teaching
includes:
• Wearing proper shoes to prevent foot problems – break new shoes in slowly.
• Drinking plenty of fluids.
• Not “over exercising”; start slowly and increase the length of time an activity is
done or the number of times it is done each week.
• Carrying a carbohydrate containing source (for example: glucose tablets,
crackers, or juice) if taking oral diabetes medications or insulin.
• Reviewing signs and symptoms of a heart attack which are: chest pain/pressure,
diaphoresis (sweating), shortness of breath, jaw pain, left arm/shoulder pain, back
pain and nausea. Also, review how to get immediate help.
It can be difficult to get people moving! At each visit reward any and all efforts patients
have made toward improving their activity level. Activity is one of the most important
tools a person can use to help control their diabetes. If you are having difficulty getting
any of your patients moving, consult the following list for ideas on how to problem-solve
the barriers your patients may present as reasons for not engaging in more activity.
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1. Problem-Solving for Barriers to Activity
a. No Time
• Get up earlier/go to bed later.
• Combine activities (playing with children, housework, dancing).
• Schedule it into your day (make a date with yourself).
• Take the stairs instead of the elevator.
• Break it into several short sessions per day.
b. Weather (Too hot! Too Cold! Too Rainy! Too Snowy!
Too Windy…)
• Walk on an indoor track (check the local high schools or colleges).
• Use exercise videos or TV programs.
• Join a fitness center or gym.
• Buy home exercise equipment.
• Get some all weather gear and get outside! (be careful of icy
weather!!!!)
c. Medical Conditions
• Talk with the physician about a physical therapy consult and/or
medications that might make activity more comfortable.
• Try warm water pool exercises.
• Suggest arm chair exercises.
• Patients with heart disease, hypertension, or diabetes complications
such as neuropathy and retinopathy require individual activity
programs that take these conditions into consideration and should be
discussed with a physician.
d. No Energy!
• Start small!! Make small achievable goals and increase as able.
• Exercise will give you energy….really it will!
e. Too Expensive
• Check with insurance companies, some cover a portion of membership
cost if you prove you attend a minimum number of times each month.
• Take out exercise videos from the library.
• Walking is cheap and you can do it anywhere!
• Look for exercise equipment at yard sales.
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f. Boring / No Motivation
• Choose activities that will be fun (sight seeing, museum tour, ice
skating, roller skating, bowling, swimming, etc).
• Exercise with a friend.
• Use headphones to listen to music or a book on tape.
• Watch TV during exercise.
• Make a game out of it -- play with the children in your life, they are
always moving!
• Walk your neighbor’s dog!
• Get a pedometer.
2. Testing Blood Glucose and Activity
Whether your patient has type 1 or type 2 diabetes, it is important for them to test their
blood glucose when engaging in activity. If your patient has type 2 diabetes, testing
before and after activity allows them to see the glucose lowering effects of activity. For
patients with type 1 diabetes testing prior to activity helps them determine if a snack is
needed before the activity. Blood glucose response to physical activity is affected by the
type, amount, and intensity of the activity; the timing and type of previous meal and
medication; the pre-activity blood glucose level; and the fitness level of the individual.6
High blood glucose levels are a concern prior to activity. In general it is a good idea for
patients with Type 1 diabetes to avoid activity if blood glucose levels are > 250 mg/dl or
if ketones are present since this can result in further rises in both blood glucose levels as
well as ketosis. Patients with Type 2 diabetes should be cautious when glucose levels are
> 300 mg/dl.7 For individualized patient information you should consult their diabetes
provider.
3. Hypoglycemia
Exercise may lower blood glucose levels during the exercise and can last for up to 12-24
hours. If an intense activity, one which lasts for greater than one hour, is performed it is
possible to have hypoglycemic reactions as late as 12 to 24 hours later. This is called
postactivity, late-onset hypoglycemia. Patients taking certain oral diabetes medications
or insulin are at risk for hypoglycemia. To prevent hypoglycemia for both type 1 and
type 2 patients, they should be instructed by their physician to test their blood glucose
before and after activity to monitor their response. They should also either reduce their
insulin/oral diabetes medications or add a snack prior to the activity. How much
medication they reduce or food they add is based on their pre-activity blood glucose
level. For specific instructions that you can provide for your patients, consult a
physician.
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C. Methods Used to Monitor Diabetes Control
1. Tests for Glycemia
a. Blood Glucose tests are done by lab venipuncture or finger stick which
provides a snapshot of what the blood glucose is at that moment.
b. Glycohemoglobin A1c (HbA1c), now referred to simply as the A1c test,
provides a bigger picture of average blood glucose levels over the last 2-3
months. Glucose attaches or glycates to the hemoglobin of the red blood
cell, which has a lifespan of about 120 days. Therefore, the A1c reflects
the previous 3 months of glycemic control. This is typically done at the
provider’s office or lab every 3 months. Results are not recommended to
diagnose diabetes, but are used to assess efficacy of treatment and risk for
long-term complications of diabetes. The table below shows the
correlation between A1c level and mean plasma glucose levels.8
A1c Mean Plasma Glucose
4 65
5 100
6 135
7 170
8 205
9 240
10 275
11 310
12 345
c. Glycated Serum Protein (GSP), e.g. Fructosamine Assay, is a measure
of the glycation of a serum protein with a half-life of 14-20 days and thus
reflects the blood glucose control over the last 1-2 weeks. This is done at
the lab/provider’s office to document short-term changes in glycemia.
Specifically, this may be used to determine the response to new
medication, a change in an insulin regimen, or when the A1c is not
accurate as is often the case in people with hemoglobinopathies.
Since the advent of home blood glucose (BG) meters, urine glucose testing
is no longer considered a reliable method for monitoring glucose. Glucose
in the urine is not detectable unless blood glucose levels have been above
180 mg/dl.
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2. Self Monitoring of Blood Glucose
a. Benefits
• Provides information to make decisions for diabetes self-management.
• Determines and guides treatment for hypoglycemia.
• Provides information on how food, activity, medication, and stress
affect blood glucose (BG) levels.
• Identifies problem areas and patterns to determine possible causes and
adjust treatment or other variables as necessary.
b. Blood Glucose Goals
The American Diabetes Association (ADA) recommendations for BG
goals are based principally on the results of the Diabetes Control and
Complications Trial (DCCT). They recommend that most individuals
with diabetes should attempt to maintain blood glucose levels as close to
normal as possible. Goals should be individualized between patient and
provider.
ADA 2005 Clinical Practice Recommendations for Glycemic Control9
Hemoglobin A1c < 7%*
Preprandial plasma glucose 90-130 mg/dl
Peak postprandial plasma glucose < 180 mg/dl
Key concepts in setting glycemic goals:
• Goals should be individualized.
• Certain populations (children, pregnant women, elderly) require
special considerations.
• Less intensive glycemic goals may be indicated in patients with
severe or frequent hypoglycemia.
• More stringent goals (i.e., a normal A1c < 6%) may further reduce
complications at the cost of increased hypoglycemia (particularly
in those with type 1 diabetes).
• Postprandial glucose levels may be targeted if A1c goals are not
met despite reaching preprandial glucose goals.
*referenced to a non-diabetic range of 4.0 - 6.0% using a DCCT based
assay.
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Note: Blood glucose recommendations are plasma values. If still using a
monitor that gives whole blood results, the goals pre-meal would
be 80-120 mg/dl, 10-15% lower.
c. How to Choose a Blood Glucose Meter
Considerations for selecting a blood glucose meter include the individual’s
abilities, lifestyle, and preference. Most diabetes educators recommend meter
upgrades using the newer technology, which improves ease of use and accuracy.
No more hanging drops, timing, wiping and cleaning. Meter memory with date
and time are now standard features. Many now come with cables and software
that allow users and providers to download results to computers for easy to read
printouts.
1. Questions to Ask Your Patients
• Can they see the display?
• Can they handle the strip?
• Can they provide the adequate blood droplet?
• Can they apply the blood to the strip?
• Can they code the meter?
• Can they do a control test?
• Do they know whom to contact with questions regarding their
meter?
• Is the meter plasma calibrated or are results given in whole
blood values?
• Is the meter approved for alternate site testing?
• Do they know when they should/should not use alternate site
testing?
d. Tips on Blood Glucose Testing
• Wash hands!!!! Substances on the skin can interfere with results. If
alcohol is used, let it dry completely.
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• If obtaining a sample is difficult, try warming and dangling the hand
first then increase the penetration depth of the lancet if needed.
• Alternate site testing is not recommended during periods of rapid BG
change, e.g. after meals, within 2 hours of taking rapid acting insulin,
after exercise, or if hypoglycemia is suspected. Fingertip testing at
these times more accurately reflects current BG levels.
• Quality meters have a customer service 800# listed on the back of the
meter for questions.
• Most insurance companies help cover testing supplies. Maine Public
Law 592 requires all Maine based insurance companies provide some
type of coverage of testing supplies. Medicare Part B currently covers
80% of testing supplies. Medicare requires a detailed prescription
including diagnosis code, frequency of testing, and most recent A1c
result.
• Lancets become dull after each use. A fresh lancet should be used at
least every 24 hours to prevent infection.
• Dispose of lancets in a non-breakable container such as a thick plastic
laundry detergent bottle or coffee can with a secured lid. Label the
container “Do not recycle.” When full be sure to put into the regular
trash, not the recycle bin.
Note: For more on glucose meters see the Diabetes Health Product
Reference Guide in the back of this section.
e. How Often to Test Blood Glucose Levels
The frequency of self monitoring of blood glucose levels is individualized based
on treatment and goals. The more tests done, the more data available to better
assess control.
• Testing can be done 1-8x per day.
• Testing should be done either before a meal or bedtime, 2 hours after a
meal, and sometimes between 2:00 a.m. - 3:00 a.m.
• Testing before meals and also 2 hours after meals allows for
evaluation of both food intake and medication effect.
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• If taking insulin, a good rule of thumb is to test the same number of
times each day as taking insulin shots; e.g. if taking 4 shots per day,
test 4x/day, if taking 2 shots per day, test 2x/day.
• Testing should be done more frequently during treatment changes.
• If testing 1-2x/day or taking a combination insulin it is recommended
the tests be rotated. This means to test at different times on different
days; e.g., Monday test before breakfast and dinner, Tuesday before
lunch and bed, and alternate this pattern every other day. Use this
information to identify patterns in BG levels.
• Test more frequently if having hypoglycemic unawareness.
• Test if suspect hypoglycemia.
• Test every 2-4 hours when ill.
• Test before driving.
• Test before, during, and after exercise as needed.
f. Keeping a Blood Glucose Log
Keeping a record of BG results and comments regarding activity and food intake
can assist with problem solving. Are values lower on days with more activity?
Are they higher on the weekend? Did the patient eat more than their meal plan
allows last night? Recording BG levels in vertical columns for same time of day
can assist the individual and provider in identifying patterns and trends and can
help guide exercise, meal and medication plans.
g. Alternative testing sites
Many meters are now available to provide glucose results taken from the fingertip
as well as other sites on the body such a the palm, forearm, upper arm, thigh and
calf. This allows a break for the fingertips which is a welcome alternative for
many. However, there has been controversy about when these alternative sites
should be used. It has been shown by some researchers that testing after meals
revealed a difference in test results between the forearm and fingertip. Fingertip
testing is the most accurate. If an alternative site is used, be sure to use the clear
cap with the lancet device which comes with the meter. Below are listed the
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times when a patient should avoid alternative site testing and instead use their
fingertip:
• When feeling hypoglycemic
• Two hours after meals
Note: A blood glucose log example is located in the back of this section.
D. Oral Medication Therapy
To best understand the medications used to treat diabetes, it is helpful to review the cause
of hyperglycemia. Is it from an absolute deficiency of insulin as in type 1 diabetes? Or is
it from insulin resistance, excess release of glucose from the liver, and/or a relative
insulin deficiency as in type 2 diabetes?
In type 1 diabetes (formerly referred to as “insulin dependent” or “IDDM”), the body
does not make insulin. Exogenous insulin is required to sustain life. Injection into the
subcutaneous tissue is the only approved route of administration at this time. Research
continues on other forms including pills that can avoid digestion by the stomach and
insulin that can be inhaled.
Insulin regimens are used to mimic what a normal pancreas would do (e.g. provide a
background level of insulin to maintain blood glucose levels and provide additional
insulin at meal times to compensate for the rise in postprandial glucose). Different
insulin combinations are used to duplicate this effect.
Currently, best glycemic control is achieved with: 1) a QID regimen (4 shots per day)
using a daily long acting insulin (basal) and rapid acting insulin at meals; or 2) Insulin
pump therapy (continuous subcutaneous insulin infusion – CSII), this provides
continuous infusion of a rapid acting insulin via a catheter inserted under the skin. A
BID regimen (2 shots per day) consists of combining a short or rapid acting insulin and
an intermediate acting insulin and would be taken before breakfast and dinner.
In type 2 diabetes (formerly referred to as “non-insulin dependent” or “NIDDM”),
medication is added when medical nutrition therapy (meal planning) and exercise fail to
achieve glycemic control or when the pancreas no longer is able to supply the insulin
needed to control BG levels. Treatment is aimed at the underlying reasons for
hyperglycemia: insulin resistance, excess hepatic glucose and insulin deficiency.
There are five classes of oral medications. Each class works in different ways to control
blood glucose and are typically used in combination with each other or insulin. While
many augment the insulin supply like the Sulfonylureas and the Meglitinides (i.e.
stimulate the pancreas to secrete more insulin), several enhance the effectiveness of
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endogenous insulin (i.e. allow one’s own insulin to work better) as do the Biguanides,
Thiazolidinediones, and Alpha-glucosidase Inhibitors.
The Biguanides (metformin) inhibit the liver from releasing too much glucose and also
help to sensitize the muscle cells to insulin. The Thiazolidinediones (TZD’s) (Actos &
Avandia), make fat cells and muscle cells more sensitive to insulin. Alpha-glucosidase
Inhibitor’s (Precose & Glyset) main site of action is the intestine; they slow the
digestion of some carbohydrates. The Meglitinides (Prandin & Starlix) stimulate the
pancreas to secrete more insulin but only in response to a rise in glucose levels.
Generally speaking, Alpha-glucosidase Inhibitors reduce the A1c 0.5-1% while all
others typically lower it 1-2%.10 When agents are combined, their efficacy is generally
additive. Currently there are 3 oral medications that combine the above: Glucovance,
Metaglip, and Avandamet.
Insulin therapy can be used alone or in combination with oral agents to help patients
achieve and/or improve target glucose control. If contraindications exist, or
combinations of oral agents fail to achieve glycemic goals, the addition of insulin is
indicated. If an individual with type 2 diabetes requires insulin for control, they still have
type 2 diabetes; they do not suddenly become type 1. This is often mistaken. Key
teaching points for patients on oral medications should include how they work, when they
should be taken in relation to food, possible side effects, contraindications, and
particularly precautions and treatment for hypoglycemia.
Note: Oral medication options are limited for patients with hepatic or renal dysfunction,
CHF, advanced age, and pregnancy.
Note: A list of oral medications is available in the Diabetes Health Product Reference
Guide located in the back of this section.
E. Insulin Basics
Insulins have different properties; type, concentration, purity, and source that determine
their time-activity profiles (in other words how they work).
Note: Time Activity Profiles are in the back of this section.
1. Type refers to the onset, peak, and duration of its action. Each type is
considered to be either rapid-acting, short-acting, intermediate-acting or longacting.
Usually an intermediate or long-acting insulin is used in conjunction
with short or rapid acting insulin. Pre-mixed insulins are also available.
These are insulin preparations with a predetermined proportion of insulins,
e.g. 70% intermediate acting with 30% short acting insulin.
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2. Concentration refers to the strength of insulin. All of the insulin used in the
United States is U-100 concentration; 100 units per milliliter. U-500 insulin is
available by special order only.
3. Purity of insulin is expressed as parts per million of proinsulin, the primary
contaminant after extraction from animal pancreas or dissolution of cells used
for recombinant DNA reproduction of insulin molecules. Purity of insulin is
almost a non-issue today as all insulins are highly purified.
4. Sources of insulin before 1983 were from beef and pork pancreas. Human
insulin is now the most prescribed. Beef sources were discontinued in 1994.
Human insulin is produced synthetically by recombinant DNA technology
(biosynthetic) or by a chemical conversion of pork insulin to human insulin
(semi-synthetic). Insulin analogs (Humalog and Novolog) have been
developed through the modification of the amino acid sequence of the insulin
molecule.
Side Effects to insulin include local and general allergy, hypoglycemia, weight gain,
decreased serum potassium, and changes in fat tissue at the injection site. Insulin is
administered by syringe, insulin pen or insulin pump. Insulin pens may be carried in a
purse or shirt pocket and therefore make it easier for patients to adhere to their insulin
regimen.
F. Insulin Pumps
Insulin pumps provide a continuous delivery of rapid acting insulin. Insulin pumps allow
owners to have greater flexibility in managing their diabetes. The major advantages of an
insulin pump are improved insulin absorption; the ability to change the amount of insulin
delivered at any time throughout the day due to changes in exercise, food intake, stress,
illness, hormonal changes, and certain medications; as well as less daily injections.
Disadvantages that need to be considered are: being connected to a medical device all
the time, the protection of long acting insulin is not available (therefore if a pump fails to
work, DKA can have a rapid onset), and there may be an increase in the cost of supplies
for a pump versus traditional syringes.
Pump wearers (also frequently referred to as “pumpers”) learn how to program their
pump to deliver a basal rate (for background needs) and a bolus (to cover food). They
may give extra insulin when blood glucose levels are high or they would like to enjoy an
extra snack or dessert. They are also able to program a temporary basal rate to reduce
their insulin during exercise or increase it as is often necessary during illness.
Education provided to pumpers is extensive. Since an insulin pump is merely another
method used to deliver insulin, pumpers still need to know the basics of how to treat
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hypoglycemia, illness, and hyperglycemia. They need to be testing their blood glucose
levels at a minimum of four times per day, testing for ketones when appropriate; and
counting the carbohydrates in the foods they eat. In addition to these basics, pumpers
need to know how to identify problems with their pump, pump site, and insulin; as well
as how and when to set the pump aside and correct problems using a syringe and insulin.
Diabetic Ketoacidosis has a rapid onset so being able to identify and attend to these
problems immediately is crucial.
A good insulin regimen is one that achieves targeted glucose goals, minimizes
hypoglycemia, and is acceptable to the patient.
Note: It is important to remember that individuals respond differently to insulin doses.
Disposal of syringes and needles:
Dispose of syringes in a non-breakable container such as a thick plastic laundry detergent
bottle or coffee can with a secure lid. Label the container “Do Not Recycle.” When full,
be sure to put into the regular trash, not the recycle bin.
.
G. Insulin Guidelines and Pens
Note: Guidelines for the Use of Insulin and Special Guidelines for Insulin Pen Use are
located in the back of this section.
H. Incretin Mimetics
Byetta (exenatide) is an injectable diabetes medication for type 2 diabetes. It is the first
medication in a new class called Incretin Mimetics. Byetta is currently indicated for use
with patients who have not yet achieved adequate blood glucose control taking
metformin, a sulfonylurea (glyburide, glynase, glipizide) or both.
Byetta “mimics” the glucose lowering effects of the human incretin hormone known as
glucagon-like peptide-1 (GLP-1). This is secreted in response to food intake. GLP-1 has
many effects on the stomach, liver, pancreas, and brain that work together to regulate
blood glucose. These effects include:
• Stimulating the body’s ability to produce insulin in response to a rise in blood
glucose level.
• Preventing the release of the hormone glucagon following meals.
• Slowing the rate of nutrient absorption.
• Reducing food intake.
The most common reported side effect of Byetta is nausea, or a sense of fullness. This
typically occurred in the first few weeks of therapy and then improved. In fewer cases
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vomiting, diarrhea, jitteriness, dizziness, and headache occurred. Byetta used alone does
not cause hypoglycemia. However, it may cause other diabetes medications to work
better. Caution patients to be prepared to treat hypoglycemia.
Note: Guidelines for the Use of Byetta and Special Guidelines for Byetta Pen use are
located in the back of this section.11
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Blood Glucose Log
Name________________________
Date
Before
Bkfast
After
Bkfast
Before
Lunch
After
Lunch
Before
Supper
After
Supper
Before
Bed
Comments
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Guidelines for the Use of Insulin
Patient Instructions
Timing of Insulin Dose:
Each insulin starts working and peaks at different times. It is important that you use the
following guidelines for the timing of your insulin:
• Never skip an injection (even if you are sick and cannot eat) without
consulting with your diabetes team first.
• For Regular (R) insulin, take your shot one half hour before your meal.
• For Humalog (H) insulin or Novolog, take your shot within 15 minutes of
your meal (usually just before eating).
• For Long Acting (NPH, Lente) or Basal (Lantus) insulin take your shot at a
consistent time of day.
Drawing Up and Mixing Insulins:
• Do not use insulin if you notice clumps in it, or if there are color changes.
• Always wipe the tops of your insulin vials or pens with alcohol before using.
• Roll vials of NPH, 70/30 or 75/25(cloudy insulin) before drawing up the
insulin dose.
• Turn back and forth the pens of NPH, 70/30 or 75/25(cloudy insulin) before
dialing or counting the insulin dose.
• When mixing two types of insulin in the same syringe, always make sure to
draw up the short-acting (Regular or Humalog) first.
• Lantus insulin CANNOT be mixed in the same syringe with any other insulin.
Injecting Insulin:
It is important that the insulin be injected into the fat layer and not the muscle. For this
reason we recommend:
• Clean site
• Pinch up the skin
• Hold the syringe like a dart and push straight into the skin
• Inject the insulin
• Release the pinch after 3-5 seconds
• Pull out the syringe
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Injection Site Options:
• Stomach (avoid 2 inches around belly button) – absorbs
at faster speed.
• Outside of upper arms – absorbs at medium speed.
• Top and outer side of thighs – absorbs at slower speed.
• Upper part of buttocks – absorbs at very slow speed.
Note: We recommend stomach and thighs, unless somebody else is giving
you the injection.
It is recommended that you use the same site for injection at the same
time of day (for instance use your thighs in the morning and your
stomach in the evening). You should rotate where you inject within that
site so you aren’t going in the same spot over and over again. Avoid
areas of fat buildup, hardening or scarring. Notify your health care
provider if you note any changes at injection sites.
Syringe Reuse and Disposal:
• Many people safely reuse their syringes for up to 24 hours.
• If you choose to reuse your syringe, you cannot use the same syringe for
Lantus that you’ve used for other insulins. If someone else fills the syringes
for you, do not reuse these to prevent needle stick injuries.
• Once you are done with your syringe put it in a heavy plastic container such
as a laundry detergent bottle. When it is near full, tape the cover closed and
label it “do not recycle.”
• Contact your local city or town to ask if it is safe to put the full container in
the trash.
Storage of Insulin:
• It is the manufacturer’s recommendation that you store insulin in the
refrigerator.
• Short acting insulin pens (Humalog and Regular), and any vial of insulin
(short and long acting), are good for one month.
• Longer acting insulin pens are good at room temperature fewer days: 14 days
for NPH insulin pens and 10 days for 70/30 or 75/25 insulin pens.
• If you store insulin at room temperature make sure it is not stored in direct
sunlight, in a bathroom that may get hot and humid, above a stove, in a car
when it’s hot or cold, or anyplace there may be extremes in temperatures.
• Once a vial of insulin has been opened, it should be discarded after one month
regardless of where it has been stored.
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Special Guidelines for Insulin Pen Use
• If your pen has long acting insulin (NPH, 70/30 or 75/25) you must mix the
insulin first by inverting the pen (turn up and down) 15-20 times.
• You need to push air out of the needle before every injection. To do this “air
shot” dial 2 units and inject the insulin into the air. Then you can dial the dose of
insulin you need to give yourself.
• After injecting the insulin you must slowly count to 5 before taking the needle out
of your skin.
• Be sure the dose knob is fully depressed each time to ensure you receive the full
dose. For Novolog Pen and Innolet doser, check that the dose dial reads “0”; for
Lilly pen, check that the dose knob rotates freely.
• Always remove the needle from the pen after you’ve injected the insulin so
bacteria and air cannot get into the insulin. Do not carry the pen around with a
needle on it for this same reason.
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Guidelines for the Use of Byetta
Patient Instructions
When starting Byetta, you need to remember that no medication by itself will control
your diabetes. All medications, including Byetta, will work best when combined with
increased activity and a sensible meal plan.
Timing of Byetta Dose:
• The starting dose is 5 mcg per injection, this will increase to 10 mcg after the
first month.
• Inject 60 minutes before breakfast and dinner.
• If you forget to take your dose and have already eaten, skip that dose and get
back on track for the next one.
• Should you need to take antibiotics, oral contraceptives, or thyroid medication
they need to be given one hour prior to Byetta or at a different time of day
such as noon or bedtime.
Dialing Dose :
• The first time you use each pen you need to dial a dose and waste it – this
primes the pen. Each following injection you only need to apply a new needle
and inject.
• Do not use the medication if you notice clumps in it, or if there are color
changes.
• Always wipe the tops of the pen with alcohol before applying the pen needle.
• See back of this page for specific dialing dose instructions.
Injecting Byetta:
It is important that Byetta be injected into the fat layer and not the muscle. For this
reason we recommend:
• Clean site
• Pinch up the skin
• Hold the syringe like a dart and push straight into the skin
• Inject the insulin
• Release the pinch after 3-5 seconds
• Pull out the syringe
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Injection Site Options:
• Stomach (avoid 2 inches around belly button)
• Outside of upper arms
• Top and outer side of thighs
• Upper part of buttocks
Note: We recommend stomach and thighs (unless somebody else is
giving you the injection).
You should rotate where you inject within that site so you aren’t going
in the same spot over and over again. Avoid areas of fat buildup,
hardening or scarring. Notify your health care provider if you notice any
changes at injection sites.
Pen Needle Reuse and Disposal:
• It is not recommended you reuse pen needles.
• Do not leave needles attached to the pen, remove and discard properly after
each use.
• Once you are done with your needle put it in a heavy plastic container such as
a laundry detergent bottle. When it is near full, tape the cover closed and
label it “do not recycle.”
• Contact your local city or town to ask if it is safe to put the full container in
the trash.
Storage of Byetta:
• It is the manufacturer’s recommendation that you store Byetta in the
refrigerator at all times.
• When traveling keep Byetta cool by wrapping it in a small piece of cloth and
placing in a cooler or use a small carrying case with a small cold pack. Avoid
placing directly against ice or cool packs. Do not use if it freezes. Protect the
pen from sunlight. Each pen should be discarded after 30 days.
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Special Guidelines for Byetta Pen Use
• You need to push air out of the needle before the first injection when you open a
new pen. To do this “air shot” dial one full dose (either 5 mcg or 10 mcg) and
inject the medication into the air/sink. Then you can dial the dose of Byetta you
need to give yourself. Each following injection you can simply apply the needle,
dial the dose and inject.
• After injection Byetta, you must slowly count to 5 before taking the needle out of
your skin.
• Always remove the needle from the pen after you’ve injected Byetta so bacteria
cannot get into the medication. Do not carry the pen around with a needle on it
for this same reason.
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V. ACUTE COMPLICATIONS
A. Hypoglycemia (Low Blood Glucose)
Hypoglycemia occurs when blood glucose levels fall below 70 mg/dl. When this
happens, most people have unpleasant symptoms. These symptoms usually come on very
suddenly. Hypoglycemia is easy to treat and easy to avoid!
1. Symptoms
There are early, moderate and late/severe stages of symptoms. Instruct your patients to
monitor their blood glucose level and treat at the first sign of any symptoms.
2. Causes
• Taking more diabetes oral medication or insulin than needed
• Skipping meals or not eating enough (especially carbohydrates)
• More activity than usual
• Taking medication at the wrong time
• Drinking alcohol
According to the ADA, daily alcohol intake should be limited to 1 drink for
women and 2 for men. One serving is equal to 12 ounces of beer, 5 ounces of
wine or 1.5 ounces of distilled spirits.12 Light to moderate amounts decrease the
risk of heart disease. The danger of drinking alcohol can be low blood glucose
levels for any person taking insulin or oral diabetes medication and can happen
12-16 hrs after significant alcohol intake.
EARLY MODERATE LATE/SEVERE
Shaky Slurred speech Seizures
Sweaty Confusion Unconsciousness
Weak Lethargy
Hungry
Dizzy or lightheaded
Headache
Palpitations
Blurred vision
Some people have
no symptoms at all
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Alcohol consumption should be discussed with the provider. If approved, the
following guidelines are offered for many patients:
• No more than 1 drink for women and 2 drinks for men no more than 2
times per week with food.
• Do not drink alcohol on an empty stomach.
• Limit or avoid altogether drinks that contain large amounts of sugar such
as liquors, sweet wines and sweet mixers.
• Avoid alcohol if diabetes is in poor control. Wait until blood glucose
levels are in better control.
• Avoid alcohol if triglycerides are elevated since alcohol tends to raise
them.
3. Treatment
Hypoglycemia needs to be treated immediately. It is recommended that people taking
oral diabetes medication or insulin keep carbohydrate sources on hand at all times in case
of a hypoglycemic reaction. Some people feel the symptoms of hypoglycemia when their
blood glucose is < 80 mg/dl. However, most do not feel symptoms until < 70mg/dl. Any
patient should use the “Rule of 15” to treat hypoglycemia when blood glucose levels fall
below 70 mg/dl.
Rule of 15
a. Test your blood glucose if feeling symptomatic
b. If < 70 mg/dl, take 15 grams of carbohydrate
Examples of 15 grams of carbohydrate:
• 4 oz. juice
• 3-4 glucose tablets
• 2 tbsp. raisins
• 4-5 oz. regular soda
• 10 oz. skim or lowfat milk
c. Wait 15 minutes
d. Retest your blood glucose
e. If < 70 mg/dl, then treat again with 15 grams of carbohydrate;
continue treating until BG > 70 mg/dl.
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Never force food or drink into the mouth of someone who may be having a
hypoglycemic reaction; this could cause choking. Instead, try to offer a drink of
juice, milk, or regular soda. Often people will follow directions to drink or eat
even when they are unable to verbalize this need.
For unconsciousness suspected to be hypoglycemia, give glucagon, a hormone
that causes stored glucose in the liver to be released into the bloodstream. It is
available by prescription only and does have an expiration date. This needs to be
reconstituted before injecting SC or IM. Patients with type 1 diabetes should be
encouraged to keep a glucagon injection kit at home at all times and when
traveling.
4. Prevention
• Avoid skipping meals or snacks
• Monitor blood glucose levels on a regular basis
• Teach patients to adjust their food and insulin when increasing or decreasing
their activity level
5. Medic-Alert Identification
It is recommended that any person taking oral diabetes medication and/or insulin
wear medic-alert identification. In an emergency it may help others to identify
why a person is acting as they are, such as confused. It can also help emergency
personnel care better for a person in an accident or some other event when they
are unable to speak for themselves.
B. Hyperglycemia (High Blood Glucose)
Normally, for someone without diabetes, fasting blood glucose levels are maintained
between 60-115 mg/dl. For diagnostic purposes, hyperglycemia occurs when fasting
blood glucose levels rise above 125 mg/dl. Remember that pre-diabetes exists when
fasting blood glucose levels are between 100-125 mg/dl. Blood glucose levels change
constantly depending on many factors.
1. Symptoms
• Increased hunger
• Increased thirst
• Increased urination
• Fatigue
• Blurred vision
• Frequent infections
• Slow healing of cuts or sores
• Weight loss
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Note: In many individuals glucose levels rise at such a slow rate they adjust to
the increasing levels without noticing.
2. Causes
• Eating more food than meal plan allows
• Emotional stress
• Illness/pain/surgery/infection
• Not taking enough diabetes medication or taking it at the wrong time
• Certain medications (i.e., prednisone)
3. Treatment
Regardless if a patient has diabetes or pre-diabetes, the recommended lifestyle
changes are the same:
• Meal planning – decreasing portion sizes, limiting high fat foods, drinking
mostly calorie-free beverages.
• Exercise – any kind of activity beyond what a person is currently doing
will help to lower blood glucose levels.
• Weight loss – even a modest weight loss helps the cells of the body to use
glucose better.
• Monitoring blood glucose levels – knowing current blood glucose levels
helps people make decisions about self care (need to take a walk, need to
eat less/more, need to manage stress better, etc.).
As previously discussed, there are several types of oral medications and insulins
to help control blood glucose levels.
4. Prevention
• Follow the meal plan.
• Increase activity.
• See the doctor for any cuts/sores that do not heal quickly.
• Take medications at the right times.
C. Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis is a serious complication of diabetes. It is caused by a lack of
insulin or an elevation in stress hormones which increases insulin resistance. When
insulin levels are low, glucose stays in the bloodstream. The body looks for an alternate
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energy source and breaks down fat for fuel. The by-product of this process are acids
called ketones.
Some people are more prone to developing ketones than others. Ketoacidosis is more
common for people with type 1 diabetes, however people with type 2 have also
developed this. Ketoacidosis may occur with illness, or during periods of increased
stress, or with poor insulin adherence.
1. Symptoms
• Nausea or vomiting
• Abdominal pain
• Increased thirst/dehydration
• Chest pain
• Fruity smelling breath
• Clouding sensorium
• Shortness of breath
2. Causes
• Lack of insulin
• Elevation of stress hormones
3. Treatment
Ketoacidosis is a serious complication of hyperglycemia and needs to be treated
immediately clearing the body of ketones requires:
a. Blood glucose testing – at least every 4 hours while sick.
b. Urine ketone testing – this is done by holding a ketone test strip in the
urine stream; after 15 seconds the color is compared to the color code
on the bottle – the deeper purple color means the more ketones a
person has.
• Test for ketones with every urine while sick as well as anytime
blood glucose is > 240 mg/dl twice in a row.
c. Increasing fluids ½-1 c per hour; switch to salty fluids if vomiting or
diarrhea occur, or if ketones are present. Fluids are critical in
preventing dehydration.
d. Extra short acting insulin is given with physician guidance generally
every 2-3 hours while the blood glucose is high and there is presence
of moderate to large ketones.
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e. Possible hospitalization for IV hydration and correction of electrolyte
imbalances.
Note: Ketostix may be purchased in a vial, expiring in 6 months, or foil
wrapped, expiring as dated (this may be as long as 1 – 2 years or longer).
4. Prevention
• Take all medications/insulin as prescribed.
• Treat any and all illnesses in a timely manner.
• Test for ketones when blood glucose is ≥ 240 mg/dl twice in a row and/or
when ill.
• Flu shot.
• Pneumovax.
Note: There are dual function meters that test both blood glucose and ketone
levels.
D. Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS)
Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS) is a serious problem that
occurs in people with type 2 diabetes.
1. Symptoms
• Higher than normal blood glucose levels (e.g., 600’s)
• Excessive thirst
• Increased urination
• Hunger
• Nausea or vomiting
• Rapid shallow breathing
2. Causes
Causes are high blood glucose levels that eventually cause dehydration and
electrolyte imbalances. This is most common in elderly patients. It usually
develops over a period of days as a result of high blood glucose levels, illness,
and/or dehydration.
3. Treatment
• Treat the illness that is causing the high blood glucose levels.
• If antibiotics are prescribed, take all pills as directed.
• Alert the doctor caring for the person that they have diabetes.
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• Prevent or treat dehydration!
• Drink ½ to 1 cup of fluid every 30-60 min; if unable to drink much, switch
to salty fluids such as bouillon, broth or soup.
• Hospitalization may be required for IV hydration and correction of
electrolyte imbalances.
4. Prevention
Instruct patients to do the following:
• Follow sick day guidelines for adequate hydration, self monitoring of
blood glucose levels and when to call the doctor.
• Take all medications as prescribed – never skip them.
• Monitor blood glucose levels more often.
• Test urine for ketones if blood sugar is > 300 mg/dl.
• Flu shot.
• Pneumovax.
E. Sick Day Guidelines
High blood glucose levels due to illness can turn a minor illness into a major
problem. When the body is under stress from illness or pain, it releases hormones
to help fight disease or make repairs as necessary. These hormones cause blood
glucose levels to rise and interfere with the blood glucose lowering effects of oral
medications and insulin. Higher blood glucose levels during an illness left
untreated can lead to Diabetic Ketoacidosis or Hyperosmolar Hyperglycemic
Non-Ketotic Syndrome. Both conditions are dangerous and can be lifethreatening.
1. What Patients Should Do When Ill:
• Test blood glucose at least every 4 hours.
• If type 1 diabetes, test urine for ketones with every void.
• Increase fluids → ½-1 c of fluid per hour – change to salty fluids for
vomiting or diarrhea (bouillon, broth, soup, etc.).
• If unable to eat usual foods, switch to sick day food list.*
• Give extra short acting insulin as directed by the provider
• Instruct patients to call their doctor if:
o Moderate to large ketones appear after testing.
o Vomiting occurs more than twice or continues for > 6 hours.
o Unable to keep fluids down.
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o Blood glucose levels are > 240 mg/dl despite taking extra insulin.
o Blood glucose is > 240 mg/dl for more than 24 hours for patients
with type 2 diabetes.
o They do not know how to care for themselves.
2. Prevention
• Yearly flu shot
• Pneumonia shot
*Note: The sick day food list is in the back of this section.
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Sick Day Foods
If you are unable to eat your usual foods, replace each 15 grams of carbohydrate in your
usual meal with any of the fluids or soft foods listed below. Each of the foods in the
amount listed below have 15 grams of carbohydrate.
Foods/Beverages Amount
Custard, regular 1/2 cup
Fruit juices (except grape) 1/2 cup
Grape juice 1/3 cup
Honey 3 teaspoons
Ice cream 1/2 cup
Jell-o (regular) 1/3 cup
Milk 1 and 1/4 cups (10 ounces)
Milk shakes 1/4 cup
Popsicle (regular) 1 whole
Saltine crackers 6 each
Sherbet 1/4 cup
Soda pop (containing sugar) 3/4 cup
Soups (broth based, reconstituted with
water or cream)
1 cup
Sports drinks (Gatorade) 1 cup
Toast 1 slice
Yogurt (with Aspartame/Nutrasweet) 1 cup
Yogurt (regular) 3 ounces
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VI. STRESS AND DIABETES
As we all know, stress can occur at any time. Both the environment and people influence
stress. Positive and negative situations can be stressful. It is important to be aware of the
impact that stress has on people with diabetes because stress raises blood glucose levels.
This occurs for two reasons: (1) the hormones released when a person is under stress
may cause blood glucose levels to rise, and (2) a person may not care for themselves or
their diabetes when under stress. For example: they may revert to smoking, discontinue
their medications, stray from their meal plan, or stop testing their blood glucose levels.
A. Sources of Stress
• An illness or infection (even a cold)
• Intense emotions – fear, sadness or anger
• Worry
• Pain
B. Getting a Handle on Stress
Recognizing stress as an ongoing part of life may be the first step to dealing with it.
Encourage patients to try one of the following:
1. Work Off Stress
If you are angry or upset, try to blow off steam physically by engaging in an
activity that you enjoy, such as tennis, running or gardening. Even a walk can
help.
2. Talk Out Your Worries
It helps to share worries with someone that you trust and respect. Sometimes
another person can help you see another side of the problem and thus, a new
solution.
3. Learn to Accept What You Cannot Change
If the problem is beyond your control at the time, try your best to accept it until
you can change it. It beats spinning your wheels and going nowhere. Ask
yourself, “Can I do anything to change this?” If the answer is no, move onto
something else you can feel in charge of.
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4. Get Enough Sleep and Rest
Lack of sleep can lessen your ability to cope with stress.
5. Balance Work and Recreation
“All work and no play can make Jack a nervous wreck!” Schedule time for fun to
relax your mind. Although inactivity can cause boredom, a little loafing now and
then can ease stress.
6. Do Something for Others
Doing for others can make you feel better and can help you to see what others are
dealing with. It may help to put your worries into a different perspective.
Contributing to an individual person or group can help you see that you did
indeed make a difference for someone else today!
7. Take One Thing at a Time
It’s helpful for many of us to make a list detailing what we need to accomplish.
However, this can also feel overwhelming and defeating if the list is too big, so
start small. Break your list down to “today” and “later” to help you focus on the
most urgent issues.
8. Learn to Compromise
If your stress is other people, try giving in once in a while – maybe soon they will
too.
C. Depression and Diabetes
When coping skills fail, it is important to be aware that people with diabetes are more at
risk for developing depression. Signs and symptoms of depression are: depressed mood;
loss of interest in things usually enjoyed; feeling down, depressed or hopeless; sleeping
too much or too little; poor appetite or overeating; decreased energy level; and
decreased ability to concentrate or make decisions. 13
The American Diabetes Association recommends incorporating psychological assessment
and treatment into routine care. While there are many tools available to assess
depression, the Patient Health Questionnaire (PHQ9) is being used by many MaineHealth
facilities.
Note: The Patient Health Questionnaire (PHQ9) to use when assessing your patient for
depression is in the back of this section.
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D. Diabetes and the Family
Family members are also affected by diabetes. Everyone in the family has feelings about
it. How the person with diabetes feels can reflect on how family members feel and how
they interact with each other. This in turn can influence how well blood glucose levels
are controlled.
Family members may feel angry because of the time required to take care of diabetes; or
they may feel worried that the diabetes is not being taken care of as it should be. They
also may be fearful of the potential for complications. It is important to include them in
the educational process.
Help patients to recognize how others in their family can help them take care of their
diabetes. While no one else can really take care of the patient’s diabetes except
themselves, family members can play a supportive role by:
• Eating healthy meals together
• Exercising together
• Planning and cooking healthy meals
• Going to healthcare visits together
• Attending educational programs together
• Sharing feelings/concerns
• Listening
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VII. THE CHANGE PROCESS
Consider where a patient may be in the change process when developing a plan of care.
If they are not quite ready for action, allowing them to verbalize their feelings about their
diagnosis by providing support and encouraging them to try one or two small changes at
each visit can help move them toward modifying their behavior long term. The following
are the steps they will experience during the change process:
• Pre-Contemplation – Not considering making any change.
• Contemplation – Thinking about making a change in the foreseeable
future.
• Preparation – Seriously considering making a change in the near future.
• Action – Making the change.
• Maintenance – Incorporating new behavior into a routine over an extended
period.14
Staying healthy with diabetes usually means making some changes. However, changing
habits is difficult and often feels uncomfortable. Setting goals for behavior change can
help a person make the change. It takes time to make ones that will last and set backs
may occur. Below are a few suggestions you can use with your patients when discussing
behavior change:
• Have them start with something they are willing to do.
• Encourage them to choose what they want to change, make a plan for the
change and then do the change.
• Identify a goal that is reasonable and measurable.
• Identify costs and benefits of the behavior change.
• Determine a reward (not food) when a short-term goal is accomplished.
• Write a contract if necessary between the patient and support team (RN,
LPN, MD, family, friends, diabetes educator, etc.).
• Be prepared for set backs – how will the patient deal with them? – can
they change their original goal to help them stick to it better?
A. Goal Setting Example
Susan was recently diagnosed with diabetes. She is 55 years old, married, the mother of
four children and works full time. Although it was difficult for her to find time, she
attended Diabetes Self-Management Education (DSME) classes at her local hospital. At
the end of the program, she was asked to make one behavioral goal for herself. She
decided to get up one hour earlier Monday through Friday and walk on her treadmill for
one hour.
Susan did well at first. She lost seven pounds and her blood pressure decreased from
145/94 to 138/85. Six weeks into her program, her mother became ill and her oldest
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daughter had twins. She found herself unable to continue her program and instead
invested her time into caring for her family. “After all,” she told herself, “it’s just for a
little while.” Before she knew it, two months had gone by. She had gained five pounds,
felt very fatigued, and didn’t remember the last time she checked her blood pressure. In
addition, she realized she had not been paying very close attention to her meal plan.
Susan restarted her exercise program, checked her blood pressure and pulled out her meal
plan to plan her meals for the week. She began walking on the treadmill 3 days per week
for 60 minutes, and walking with her daughter and grandsons the other two days. Within
3 weeks she was feeling better and had lost two pounds.
What helped Susan achieve her goal?
1. Being very specific about the activity (walking).
2. Being very specific about when she would walk and for how long (Mon-
Wed-Fri for 60 min).
3. Revising her plan when she found it was not working.
B. Behavior Change Goals
Patients can work with their diabetes care team to choose the most helpful ways to reach
their health goals. Behavior change goals need to be specific and measurable. If goals
are too big or vague, people may become overwhelmed by what they need to do. Also,
they may not know where to start or if they ever achieve success.
1. Long-Term Goals
A long-term goal is something a person wants to work toward and achieve at
some point in the future.
Examples of Long-Term Goals:
• Improve my A1c (or blood glucose)
• Improve my nutrition
• Improve my physical fitness
• Reach or maintain a healthy weight
• Reduce stress
• Reduce my chance for complications (problems from diabetes)
• Improve my blood pressure
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• Improve my lipids (blood fats)
• Lower my chance for heart disease
• Improve my foot care
• Get my needed tests/exams/immunizations
2. Short-Term Goals
Short-term goals are small changes made over a short period of time.
Examples of Short-Term Goals:
• I will walk for 20 minutes three days each week (Saturday,
Monday, and Wednesday) in my neighborhood.
• I will go to the mall Friday and find out when they are open for
walking.
• I will drink diet soda instead of regular soda for the next week.
• I will eat breakfast every day before I go to work.
• I will keep cut-up carrots in my refrigerator to eat for a snack.
• I will check my blood sugar on Tuesday and Saturday before
breakfast and two hours after dinner.
• I will write down all of my blood sugar results for two weeks and
bring them to my next doctor’s appointment.
• I will check my feet for cuts and sores every day when I get
dressed in the morning.
• I will use the deep breathing relaxation technique I learned today
whenever I feel tense during the next week.
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3. Acceptable Goals
Take a look at the following goals and see how they were adjusted to make them
more specific, measurable and attainable:
Unacceptable Goal:
I will lose 20 pounds.
Acceptable Goal:
I will eliminate chips as a snack; instead will try carrots
with a lowfat dip.
Unacceptable Goal:
I will lower my blood pressure.
Acceptable Goal:
I will not add salt to food and will decrease bacon & ham to
once per week.
Unacceptable Goal:
I will become more active.
Acceptable Goal:
I will walk 45 minutes at the gym Mondays, Wednesdays,
& Fridays.
Unacceptable Goal:
I will avoid hypoglycemia.
Acceptable Goal:
I will take my oral medication with meals; or
I will test my blood glucose if I have symptoms; or
I will carry carbohydrates with me at all times.
Note: Diabetes Self-Care Action Plan is located in the back of this section.
C. Diabetes Educators
A Certified Diabetes Educator (CDE) is frequently a registered nurse or a registered
dietitian, although there are other disciplines who may become certified. To become
certified, a clinician needs to complete two years and 1000 hours of direct patient
education as well as pass a national certification exam. A CDE helps people with
diabetes learn more about the disease and how to live a long, productive life with it.
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Diabetes Educators provide:
1. Comprehensive education.
2. Support.
3. Instruction for glucose meters, insulin pens, insulins & oral medications,
meal plans, and insulin pump therapy, to name a few.
In addition, educators are an invaluable resource to physicians and their office staff. To
locate an educator near you, call the Diabetes Prevention and Control Program at
(207) 287-5180 or go to http:www.maine.gov.
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VIII. DIABETES AND PREGNANCY
Planning ahead is very important for people with diabetes when considering having a
baby. High blood glucose levels can be harmful to both a mother and her unborn baby.
Even before becoming pregnant, blood glucose levels should be as close to the normal
range as possible. Keeping blood glucose levels near normal before and during
pregnancy helps protect both mother and baby; preventing miscarriages and birth defects.
Insulin needs will change during pregnancy. The Obstetrician or Diabetes Specialist may
increase insulin dosages and instruct patients to check their blood glucose levels more
often. If taking diabetes pills, the provider will switch the patient to insulin.
Patients planning to become pregnant should be encouraged to:
• Work with their health care team to get blood glucose levels as close to the
normal range as possible.
• See a provider who has experience in taking care of pregnant women with
diabetes.
• Have their eyes and kidneys checked. Pregnancy can make eye and kidney
problems worse.
• Don’t smoke, drink alcohol, or use harmful drugs.
• Follow the meal plan prescribed by the dietitian or diabetes educator to ensure
a healthy diet.
A. Preconception Visit
Any health care visit by a woman, who has diabetes and is in her childbearing years,
should be considered a preconception visit. At these visits, birth control needs should be
discussed along with any plans for pregnancy.
At each visit the provider will:
1. Take a health history and do a physical exam.
2. Take blood tests including a Hemoglobin A1c.
15
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3. Order special exams needed before becoming pregnant:
a. Kidney function test – urine screen for microalbumin*
b. Eye exam to check retina*
c. Blood pressure
d. Electrocardiogram
*Note: If kidney, heart or eye disease exists, especially if
untreated, a woman may be a risk for further
damage/complications if she becomes pregnant.
4. Look for and treat any problems (especially infertility problems).
5. Ask at every visit if she is planning to become pregnant.
6. Ask if the woman and her partner are ready to become parents; are income
and finances an issue? Being both pregnant and having diabetes can cause
emotional and financial stress.
7. Talk with the prospective parents about good blood glucose control before
planning to become pregnant. There is an increased risk of malformations
of the baby during the early weeks of conception with poor glucose
control. Therefore, it is important to obtain good blood glucose control
prior to becoming pregnant.
8. Assess the woman’s diabetes control at home. The provider may ask:
a. How do you treat low blood glucose reactions? Do you know what
to do in case of a reaction? Do you or someone else in the family
know how to use glucagon?
b. Are you willing to do your blood glucose monitoring more often,
four or more times per day?
c. If on an oral medication for diabetes, are you willing to give
yourself insulin?
d. Are you willing to use birth control until targets for diabetes
control are achieved (Hemoglobin A1c < 7%)?
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9. Take blood tests to check resistance to Rubella.
10. Encourage healthy habits such as getting enough rest and eating plenty of
fruits and vegetables; as well as discourage unhealthy habits such as
smoking and drinking alcohol. Seeing a dietitian will be encouraged, as
will exercise!
.
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IX. TESTING AND COMPETENCIES
A. Diabetes Study Guide Pretest/Post test
1. What affect does exercise usually have on blood glucose?
a. Decreases blood glucose
b. Increases blood glucose
c. Has little effect on blood glucose
d. I do not know
2. Why is it necessary that individuals with diabetes take special care of their feet?
a. A number of years of injecting insulin into the thighs can cause edema in
both the legs and the feet.
b. Flat feet are commonly associated with diabetes unless preventive
measures are used routinely.
c. Persons with diabetes may have neuropathy or poor circulation of blood to
their feet.
d. I do not know
3. An early symptom of hypoglycemia (low blood glucose) is:
a. Frequent urination
b. Dry mouth and skin
c. Feelings of nervousness
d. I do not know
4. A symptom of hyperglycemia (high blood glucose) is:
a. Increased thirst
b. Low grade fever
c. Cool, clammy skin
d. I do not know
5. What is one cause of hypoglycemia?
a. Illness
b. Skipping a meal
c. Too little exercise
d. I do not know
TARGET Diabetes Nursing Study Guide
IX-2
6. What is one cause of hyperglycemia?
a. Decreased food intake
b. Infection
c. Excessive insulin
d. I do not know
7. What is one cause of diabetic ketoacidosis?
a. Excessive exercise
b. Excessive intake of diet soft drinks over a prolonged period of time
c. Failure to take daily insulin dose(s)
d. I do not know
8. Which one of the following is the MOST appropriate initial action for a person
with diabetes to take if he/she feels that they are beginning to have a
hypoglycemic event?
a. Drink 4 ounces of orange juice
b. Drink 12 ounces of regular soda
c. Chew 1 glucose tablet
d. I do not know
9. James’ blood glucose is 240mg/dl and his urine is positive for ketones. What
should he do?
a. Call his doctor, test his blood glucose and urine every 2 hours for ketones
and continue his insulin or oral hypoglycemic agents
b. Omit his next dose of insulin or oral hypoglycemic agent and test his
blood glucose as he would normally do
c. Continue with his insulin or oral hypoglycemic agents and blood testing as
he normally would. These are normal results for individuals with diabetes
d. I do not know
10. What effect does illness have a person with diabetes’ insulin requirements?
a. Illness causes a decrease in insulin requirements
b. Illness causes an increase in insulin requirements
c. Illness causes no changes in insulin requirements
d. I do not know
11. Which of the following medications is known to increase blood glucose levels?
a. Acetaminophen
b. Ampicillin
c. Prednisone
d. I do not know
TARGET Diabetes Nursing Study Guide
IX-3
12. Which of the following blood glucose values reflects a fasting blood glucose in
the normal range?
a. 50 mg/dl
b. 95 mg/dl
c. 155 mg/dl
d. I do not know
13. Type 2 diabetes is defined as a term for individuals who have insulin resistance
and usually have relative (rather than absolute) insulin deficiency.
a. True
b. False
14. A confirmed fasting plasma glucose value > 126 mg/dl is diagnostic for diabetes.
a. True
b. False
15. With medical nutrition therapy (MNT) for persons with diabetes no food is
forbidden and can be worked into an overall plan aimed at achieving as near
normal glucose levels as possible.
a. True
b. False
16. The “Rule of 15” implies treating low blood glucose with 15 grams of
carbohydrate and waiting15 minutes to recheck blood glucose.
a. True
b. False
17. To achieve and maintain glycemic goals and to reduce complications, self-monitoring
of blood glucose (SMBG) remains the most effective intervention.
a. True
b. False
18. Rapid acting insulin (Humalog/Novolog) should be given immediately before a meal as
this insulin begins to work in 5 minutes, peaks in about 1 hour and continues to work
for 3-4 hours.
a. True
b. False
19. How long can insulin be stored at room temperature?
a. One week
b. One month
c. 3 months
d. I do not know
TARGET Diabetes Nursing Study Guide
IX-4
20. People with diabetes should check their urine for ketones when:
a. Their blood glucose is > 400
b. Their blood glucose is > 240
c. When they are ill
d. Both b and c
21. Which of the following is a physiological action of insulin?
a. Transports glucose across cell membranes for use by the cell
b. Stimulates the release of glucose stored in the liver
c. Enhances the breakdown of fats for energy
d. I do not know
22. Patients should be instructed to know when the type of insulin they take starts to work,
when it peaks and how long it lasts to prevent hypoglycemia.
a. True
b. False
Name: _____________________________________
Date Completed: _____________________________________
Supervisor: _____________________________________
Reminder: Once you have completed reading this study guide, go to:
http://www.surveymonkey.com/s.asp?A=68915169E36695
to do a brief evaluation of this learning tool.
TARGET Diabetes Nursing Study Guide
IX-5
B. Diabetes Study Guide Pretest/Post test (Answer Key)
1. What effect does exercise usually have on blood glucose?
a. Decreases blood glucose
b. Increases blood glucose
c. Has little effect on blood glucose
d. I do not know
2. Why is it necessary that individuals with diabetes take special care of their feet?
a. A number of years of injecting insulin into the thighs can cause edema in
both the legs and the feet.
b. Flat feet are commonly associated with diabetes unless preventive
measures are used routinely.
c. Persons with diabetes may have neuropathy or poor circulation of
blood to their feet.
d. I do not know
3. An early symptom of hypoglycemia (low blood glucose) is:
a. Frequent urination
b. Dry mouth and skin
c. Feelings of nervousness
d. I do not know
4. A symptom of hyperglycemia (high blood glucose) is:
a. Increased thirst
b. Low grade fever
c. Cool, clammy skin
d. I do not know
5. What is one cause of hypoglycemia?
a. Illness
b. Skipping a meal
c. Too little exercise
d. I do not know
6. What is one cause of hyperglycemia?
a. Decreased food intake
b. Infection
c. Excessive insulin
d. I do not know
TARGET Diabetes Nursing Study Guide
IX-6
7. What is one cause of diabetic ketoacidosis?
a. Excessive exercise
b. Excessive intake of diet soft drinks over a prolonged period of time
c. Failure to take daily insulin dose(s)
d. I do not know
8. Which one of the following is the MOST appropriate initial action for a person
with diabetes to take if he/she feels that they are beginning to have a
hypoglycemic event?
a. Drink 4 ounces of orange juice
b. Drink 12 ounces of regular soda
c. Chew 1 glucose tablet
d. I do not know
9. James’ blood glucose is 240mg/dl and his urine is positive for ketones. What
should he do?
a. Call his doctor, test his blood glucose and urine every 2 hours for
ketones and continue his insulin or oral hypoglycemic agents
b. Omit his next dose of insulin or oral hypoglycemic agent and test his
blood glucose as he would normally do
c. Continue with his insulin or oral hypoglycemic agents and blood testing
as he normally would. These are normal results for individuals with
diabetes
d. I do not know
10. What effect does illness have a person with diabetes’ insulin requirements?
a. Illness causes a decrease in insulin requirements
b. Illness causes an increase in insulin requirements
c. Illness causes no changes in insulin requirements
d. I do not know
11. Which of the following medications is known to increase blood glucose levels?
a. Acetaminophen
b. Ampicillin
c. Prednisone
d. I do not know
12. Which of the following blood glucose values reflects a fasting blood glucose in
the normal range?
a. 50 mg/dl
b. 95 mg/dl
c. 155 mg/dl
d. I do not know
TARGET Diabetes Nursing Study Guide
IX-7
13. Type 2 diabetes is defined as a term for individuals who have insulin resistance
and usually have relative (rather than absolute) insulin deficiency.
a. True
b. False
14. A confirmed fasting plasma glucose value > 126 mg/dl is diagnostic for diabetes.
a. True
b. False
15. With medical nutrition therapy (MNT) for persons with diabetes no food is
forbidden and can be worked into an overall plan aimed at achieving as near
normal glucose levels as possible.
a. True
b. False
16. The “Rule of 15” implies treating low blood glucose with 15 grams of
carbohydrate and waiting15 minutes to recheck blood glucose.
a. True
b. False
17. To achieve and maintain glycemic goals and to reduce complications, self-monitoring
of blood glucose (SMBG) remains the most effective intervention.
a. True
b. False
18. Rapid acting insulin (Humalog/Novolog) should be given immediately before a meal
as this insulin begins to work in 5 minutes, peaks in about 1 hour and continues to
work for 3-4 hours.
a. True
b. False
19. How long can insulin be stored at room temperature?
a. One week
b. One month
c. 3 months
d. I do not know
20. People with diabetes should check their urine for ketones when:
a. Their blood glucose is > 400
b. Their blood glucose is > 240
c. When they are ill
d. Both b and c
TARGET Diabetes Nursing Study Guide
IX-8
21. Which of the following is a physiological action of insulin?
a. Transports glucose across cell membranes for use by the cell
b. Stimulates the release of glucose stored in the liver
c. Enhances the breakdown of fats for energy
d. I do not know
22. Patients should be instructed to know when the type of insulin they take starts to work,
when it peaks and how long it lasts to prevent hypoglycemia.
a. True
b. False
Name: _____________________________________
Date Completed: _____________________________________
Supervisor: _____________________________________
TARGET Diabetes Nursing Study Guide
IX-9
C. Insulin Injection Competency
Purpose:
To appropriately deliver an insulin injection.
Skills:
• Wash hands/wear gloves
• Inspect insulin/check expiration date/verify type, brand, dose
• Roll insulin between palms (cloudy insulin)
• Clean top of bottle with alcohol
• Pull plunger down to allow air into syringe (same number of units as insulin you
wish to withdraw)
• Push needle through rubber top of vial
• Push air into vial
• Turn vial upside down
• Pull plunger down to fill syringe with desired insulin amount
• Withdraw needle from vial
• Choose appropriate injection site
• Clean site with alcohol
• Pinch up skin
• Hold syringe like dart
• Quickly insert needle to full length, straight in, 90 degrees
• Push plunger smoothly and completely, release pinch
• Pull needle straight out
• Safely discard needle in sharps disposal container
• Record medication given/site of injection
Competency:
• Identify proper storage and appearance of insulin
• Identify proper rotation of sites
• State timing of insulin/meal schedule
Name: _________________________________
Date Completed: _________________________________
Supervisor: _________________________________
TARGET Diabetes Nursing Study Guide
IX-10
D. Hypoglycemia Competency
Purpose:
To identify a hypoglycemic event and determine treatment.
Skills:
• Recognize symptoms of hypoglycemia
• Test blood glucose to confirm hypoglycemia
• Use Rule of 15 to treat hypoglycemia
• If blood glucose < 70 mg/dl, give 15 grams of carbohydrate
• Recheck blood glucose in 15 minutes
• If still < 70 mg/dl, treat with another 15 grams of carbohydrate
• Continue to treat until blood glucose > 70 mg/dl
Competency:
• Identify signs and symptoms of hypoglycemia
• Identify treatment of hypoglycemia
• Name 3 items containing 15 grams of carbohydrate
Name: _____________________________
Date Completed: _____________________________
Supervisor: _____________________________
TARGET Diabetes Nursing Study Guide
IX-11
E. Glucometer Competency
Purpose:
To develop proficiency using glucometers.
To teach patients how to operate their own glucometer.
Skills:
Meter used for demonstration to be determined by individual clinical site.
Steps:
• Battery placement
• Coding of meter
• Check expiration date of test strips
• Load lancet into lancet device
• Wash hands
• Use proper technique for obtaining blood drop and applying to test strip
• Identify how and when to use glucose solution
• How to safely discard lancets
• Record results in blood glucose log book
Competency:
Demonstrate how to properly use meter, obtain blood sample and safely discard lancets
Name: _________________________
Date Completed: _________________________
Supervisor: _________________________
TARGET Diabetes Nursing Study Guide
IX-12
F. Monofilament Competency
Purpose:
• The filament applies 10 grams of pressure to a small point on the skin
• The filament is calibrated to bend when the 10 grams of force has been applied.
• If the patient does not feel the monofilament when you apply pressure to bend it,
sensation loss has occurred in that area.
• This should be performed annually on all diabetes patients.
• The American Diabetes Association and the Bureau of Primary Health Care’s
Lower Extremities Amputation Program (LEAP) recommend visual foot
exams/inspections at each visit.
Skills:
• Show the monofilament to the patient & demonstrate that it does not hurt. (touch
hand/arm with filament)
• Have patient turn head, close eyes or look at the ceiling.
• Ask patient to inform you when they feel the monofilament touching their foot.
• Hold monofilament perpendicular to the skin and use 3 second sequence
a) touch the skin at the areas indicated on the attached diagram
b) filament bends
c) lift from the skin
• Do not use rapid movement
a) use in random sequence
b) if patient does not say yes when a certain area is touched, continue on in
your sequence. After you have completed, return to the area that was
assessed as poor and repeat the test.
• Clean the filament between uses with a 1:10 bleach solution.
Competency:
Demonstrate how to perform monofilament testing with a patient.
Name: _______________________________
Date Completed: _______________________________
Supervisor: _______________________________
TARGET Diabetes Nursing Study Guide
IX-13
G. Insulin Pen Competency
Purpose:
Insulin pens provide an alternative insulin administration method to syringes and can
contribute to increased regimen adherence.
Skills:
• Wash hands
• Check expiration date of insulin
• Identify storage guidelines of specific insulin(s)
• Gently invert preparations of NPH, 70/30, and 75/25 to thoroughly mix; this
should be done 15-20 times
• Wipe rubber stopper with alcohol
• Apply needle by dialing 2 units and pushing through
• Prime the pen needle with two units of insulin
• Correctly dial dose
• Clean skin with alcohol
• Pinch skin
• Inject straight in 90 degrees
• Deliver dose, allow 5 seconds for injection to ensure complete insulin delivery
• Release pinch, pull pen straight out
• Check to see that dose knob is fully compressed
• Remove needle after use and dispose of needle in sharps disposal container
• Store the pen currently in use without the needle on at room temperature
Competency:
• State benefits of insulin pens to special populations
• Correctly prime, dial up and deliver dose
• Apply standard precautions with needle use, removal and proper disposal
Name: ________________________________
Date Completed: ________________________________
Supervisor: ________________________________
TARGET Diabetes Nursing Study Guide
X-1
X. APPENDIX
A. Diabetes Summary
B. Pre-Diabetes
C. References
D. More Information
TARGET Diabetes Nursing Study Guide
X-2
A. Diabetes Summary
1. Prevalence
• Over 18.2 million people – 6.3% of the population – have diabetes. Of this, it
is estimated that approximately 5.2 million people do not know they have the
disease. 16
• Approximately 93,395 Maine adults are estimated to have diabetes; 64,263
have been diagnosed; 32,132 have not yet been diagnosed. 17
2. Risk Factors (criteria for testing for diabetes)
• Age ≥ 45 yrs
• Overweight BMI ≥ 25
• Blood Pressure ≥ 140/90
• Abnormal Lipid Levels
o HDL < 35 mg/dl
o Triglyceride > 250 mg/dl
• Family History (first degree relative)
• Ethnicity
o African American
o Latino
o Native America
o Pacific Islander
• History of Gestational Diabetes
• Delivering a baby > 9 lbs
• On previous test had IGT or IFG
• Other clinical conditions associated with insulin resistance (acanthosis
nigricans)
• History of vascular disease
3. Signs and Symptoms of Hyperglycemia
• “Classic”
o polydipsia (increased thirst)
o polyuria (increased urination)
o unexplained weight loss
• Fatigue
• Polyphagia (increased hunger)
• Blurred vision
• Frequent infections
• Slow healing of cuts or sores
• Numbness/tingling of hands or feet
• Sexual problems
TARGET Diabetes Nursing Study Guide
X-3
• Dry, itchy skin
• Frequently people are asymptomatic
4. Diagnostic Criteria
• The Fasting Blood Glucose (FBG) is the preferred diagnostic test. Diabetes is
diagnosed with FBG ≥ 126 mg/dl.
• Casual blood glucose (any time of day) > 200 mg/dl with symptoms of
hyperglycemia.
• Oral Glucose Tolerance Test (OGTT) with blood glucose results > 200 mg/dl
two hours after 75 gram glucose load is given.
Note: All tests need to be repeated to confirm the diagnosis.
Note: For both diabetes and pre-diabetes, testing should be considered at an
earlier age or done more frequently for overweight individuals that have
other risk factors noted above.
5. Classification
• Type 1 diabetes – auto-immune; beta cell destruction leading to absolute
insulin deficiency; only 5-10% of those diagnosed with diabetes.
• Type 2 diabetes – characterized by insulin resistance, combined with a relative
insulin deficiency; accounts for approximately 90% of people living with
diabetes.
• Gestational diabetes – diabetes during pregnancy.
• Secondary diabetes (tumors, trauma, surgery, or infection of the pancreas).
6. Diabetes is managed through:
• Meal Planning
• Physical Activity
• Medications
• Home blood glucose monitoring
• Detection and prevention of acute and chronic complications
• Managing stress
• Community resources (web sites, support groups)
• Prevention for family members (Get the word out!)
• Education is key. Knowing how to care for yourself with diabetes is the
critical factor in preventing complications and ensuring a long and productive
life.
TARGET Diabetes Nursing Study Guide
X-4
B. Pre-Diabetes – We need to treat it now!
1. Prevalence
According to the American Diabetes Association (ADA) it is estimated that
approximately 41 million Americans have pre-diabetes. 18
2. Risk Factors (criteria for testing for pre-diabetes)
• Age ≥ 45 yrs
• Overweight BMI ≥ 25
• Blood Pressure ≥ 140/90
• Abnormal Lipid Levels
o HDL < 35 mg/dl
o Triglyceride > 250 mg/dl
• Family History (first degree relative)
• Ethnicity
o African American
o Latino
o Native America
o Pacific Islander
• History of Gestational Diabetes
• Delivering a baby > 9 lbs
• On previous test had IGT or IFG
• Other clinical conditions associated with insulin resistance (acanthosis
nigricans)
• History of vascular disease
Note: For both diabetes and pre-diabetes, testing should be considered at an
earlier age or done more frequently for overweight individuals that have
other risk factors.
3. Symptoms
None
TARGET Diabetes Nursing Study Guide
X-5
4. Diagnosis
• The Fasting Blood Glucose (FBG) is the preferred diagnostic test.
Pre-diabetes is diagnosed with an Impaired Blood Glucose (IBG) of
>100 mg/dl but < 126 mg/dl.
• Impaired Glucose Tolerance (IGT) is determined by doing an Oral Glucose
Tolerance Test (OGTT) with blood glucose results = to 140-199 mg/dl two
hours after a 75 gram glucose load is given.
5. Treatment = Life Style Changes
• Increase physical activity
• Decrease portion sizes for meals and snacks
• Decrease fats
• Increase fruits and vegetables
• Weight loss
TARGET Diabetes Nursing Study Guide
X-6
C. References
American Diabetes Association website – www.diabetes.org
A Core Curriculum for Diabetes Education, American Association of Diabetes Educators,
2001.
American Diabetes Association; Michigan Diabetes Research and Training Center; Life
with Diabetes, 1997.
American Diabetes Association; Clinical Practice Recommendations, 2004.
“An Inside Look at Preventing Diabetes Complications”; 2000, Channing L. Bete
Company, Inc.
Diabetes Control and Complications Trial (DCCT); NIDDK, NIH, National Diabetes
Information Clearinghouse, website www.niddk.org
Joslin Diabetes Center, “The Joslin Guide to Diabetes”.
Aspen Medical & Nutrition Therapy, Margaret Powers.
Diabetes Health, July & August, 2004 editions.
TARGET Diabetes Nursing Study Guide
X-7
D. For More Information…..
1. General Information
American Diabetes Association
www.diabetes.org
Centers for Disease Control
www.cdc.gov/diabetes
Diabetes Mall
www.diabetes.net
Diabetes Self-Management
www.diabetesselfmanagement.com
International Diabetes Center
Minneapolis, MN
www.parknicollet.com/diabetes
MaineHealth
www.MaineHealth.org
Michigan Diabetes Research & Training Center
National Institutes for Health
www.niddk.nih.gov
Will provide free pamphlets at patient’s request on multiple topics such as
foot care, digestive problems (gastroparesis), neuropathy, coronary artery
disease, etc.
2. Subscriptions
Diabetes Forecast
Diabetes Self-Management
TARGET Diabetes Nursing Study Guide
X-8
3. Topic Specific Information
Diabetes Disease Process & Treatment
American Diabetes Association (www.diabetes.org)
Medications
• Oral medication by typing in the medication name
followed by .com (example: www.avandia.com)
• For insulin, use the brand name such as Lilly or Novolin.com
• All Pharmaceutical web sites
Complications
Retinopathy
• American Academy of Opthamology
www.aao.org
Vascular Disease
• Vascular Disease Foundation
www.vdf.org
Nephropathy
National Kidney Foundation
www.kidney.org
Neuropathy
• The Neuropathy Trust
www.neuropathy-trust.org
Nutritional Management
Lilly Pamphlet “Nutrition in the Fast Lane”
American Dietetic Association
www.eatright.org
TARGET Diabetes Nursing Study Guide
X-9
Monitoring Blood Glucose
Patient specific home glucose monitor website
Ex: One Touch Basic, Sure Step, One Touch Ultra & One Touch UltraSmart are
produced by LifeScan, please see www.LifeScan.com
Physical Activity
American Diabetes Association
www.diabetes.org
go into search and put in “exercise”
Joslin Diabetes Center
www.joslin.org
go under beginner’s guide to diabetes and click on “exercise basics”
Psychological Adjustment
See “Local Support Groups” list available from the Maine Diabetes Prevention
and Control Program (DCPC) at (207) 287-5180 or by visiting their website:
http:www.maine.gov/dhhs/bohdcfh/dcp/DPCPhome.htm
Patient Assistance Program
www.needymeds.com
TARGET Diabetes Nursing Study Guide
XI-1
XI. END NOTES
_________________
1A Core Curriculum for Diabetes Education; “Diabetes and Complications”; Marion J. Franz, MS, RD, LD,
CDE, Editor; 2003, pg. 5.
2American Diabetes Association Clinical Practice Recommendations, Supplement1, Jan. 2005, p. S5.
3A Core Curriculum for Diabetes Education; “Diabetes Education and Program Management”; Marion J.
Franz, MS, RD, LD, CDE, Editor; 2003, pg. 71.
4American Diabetes Association/Michigan Diabetes Research & Training Center “Life with Diabetes”, pg
62-63.
5.American Diabetes Association: Clinical Practice Recommendations, Supplement 1, 2005, p S12. .
6 A Core Curriculum for Diabetes Education; “Diabetes Management Therapies”; Marion J. Franz, MS,
RD. LD, CDE; 2003; pg.67.
7 A Core Curriculum for Diabetes Education; “Diabetes Management Therapies”; Marion J. Franz, MS,
RD, LD, CDE; 2003, pgs. 70-71.
8 American Diabetes Association Clinical Practice Recommendations, Vol. 27, Supplement 1, Jan. 2005,
p. S11.
9 American Diabetes Association Clinical Practice Recommendations, Vol. 28, Supplement 1, 2005, p S10.
10 Yale Diabetes Center, “Diabetes Facts & Guidelines”, Silvio E. Inzucchi, MD, 2002-2003, pg. 35.
11 Diabetes Health, “Byetta Now Available for Type 2s”; Daniel Trecroci, July, 2—5, pg 36-37.
12 Diabetes Forecast, “Is There a Place for Alcohol in Your Diabetes Meal Plan?”; Madelyn L. Wheeler,
MS, RD, FADA, CDE; August, 2003.
13Gehling, Eve, The Next Step: Depression, Newsflash, Diabetes Care and Education Practice Group of the
American Dietetic Association, Fall 2001, Vol. 22, No. 5, p.20.
14 A Core Curriculum for Diabetes Education, 4th Edition; “Diabetes Education and Program Management”;
American Diabetes Association; Marion J. Franz, MS, RD, LD, CDE Editor; 2001; pp 34 & 74.
15Adapted from the Maine Guide for Preconception Care of Women with Established Diabetes.
16American Diabetes Association, 2004; www.diabetes.org
17Department of Health and Human Services, Maine Bureau of Health, Diabetes Prevention and Control
Program, Health Fact Sheet: Diabetes in Maine, January, 2005.
18American Diabetes Association, 2004; www.diabetes.org
High-Alert Medications and Safe Practices
A s t u d y g u i d e f o r n u r s e s Marla Husch, RPh Jennifer M. Groszek, RN, BSN, MJ
Denise Rooney, RN, BSN, OCN
High-Alert Medications and Safe Practices: A study guide for nurses iii
CONTENTS
About the authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
General safety principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Intravenous heparin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Potassium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Magnesium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Phosphorus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Intravenous calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Sodium chloride 3% (hypertonic saline) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Warfarin (Coumadin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Neuromuscular blocking (paralytic) agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Chemotherapy agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Exercise answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Nursing education instructional guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Instructions for obtaining your nursing contact hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Nursing education exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
Nursing education evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
High-Alert Medications and Safe Practices: A study guide for nurses 3
The following safety principles are applicable to the administration of all medications:
• Two unique patient identifiers should be assessed prior to administering medications. Reliable choices
include those on the wristband or those that the patient can verbalize, such as name, age/date of
birth, and medical record number. Never use room number or location as an identifier.
• Allergy status is assessed prior to administration.
• The nurse understands the medication’s intended purpose and ensures the “Five Rights”:
1. Right patient
2. Right dose
3. Right route
4. Right frequency
5. Right time
• The nurse documents in a timely manner having checked the five rights.
• The patient is informed of the drug, dose, potential side effects, and any relevant laboratory values.
• “Read back and verify” is performed by anyone receiving a telephone or verbal order.
• Only hospital-approved abbreviations, acronyms, and symbols are used in documentation.
• Many medications have distinctive colors. However, never rely on color to identify a medication.
• Any medication error, near miss, or adverse drug reaction should be reported according to your
institution’s incident report system policy.You may also report systems (e.g., pumps, dispensing systems,
human systems, etc.) that appear vulnerable to error so that they can be improved.
• Consult the pharmacy as a reference for questions.
• Syringes not prepared at the bedside are labeled with the name of the medication and dose.
• A double check system is often used with the administration of certain high-alert medications.
Double checks require two clinicians to independently calculate the dose without reviewing prior
calculations.This can ensure
1. detection of error before it reaches a patient
2. early identification of systems vulnerable to human error so that they can be improved1
General safety principles
4 High-Alert Medications and Safe Practices: A study guide for nurses
General safety principles
Reference
1. The road less traveled. Huntingdon Valley, PA. Institute for Safe Medication Practices. 2002 August 21.
High-Alert Medications and Safe Practices: A study guide for nurses 5
Why are opioids identified as high-alert medications?
Opioids bind with opiate receptors at many sites in the central nervous system (e.g., brain, brain stem,
spinal cord, etc.) and peripheral nervous system, and thereby alter both the perception of and emotional
response to pain. If they are prescribed, administered, or monitored inappropriately, respiratory depression,
coma, and even death can result.
As you read this section, keep in mind these commonly reported problems associated with opioids:
• Misconceptions about addiction, tolerance, dependence, and allergies.
• Misunderstandings regarding equianalgesic dosing of opioids.
• Infusion pump errors with Patient Controlled Analgesia (PCA) and Patient Controlled Epidural
Analgesia (PCEA) are frequent.1
• Oral liquid versions of morphine and oxycodone are available in many concentrations. Mix-ups
among them have led to serious overdoses.2
• Allergic reactions occur frequently.3
• Errors related to the drug, concentration, and route.
• Confusion between hydromorphone, morphine, and oxycodone:
- Hydromorphone intravenous (IV) is five times more potent than morphine IV
- Oral hydromorphone is about three times more potent than oxycodone
• Families and friends push the PCA or PCEA button, which can lead to serious overdoses.4
• Patients receiving opioids may not be adequately monitored.This is critical during the first 24 hours
and at night because nocturnal hypoxia occurs most frequently during these periods.5
• Confusion has occurred between sustained-release and immediate-release products (e.g., Oxycontin
and oxycodone).
Opioids
6 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Back pain
Below is a case study about a patient who was at risk for overdose because of inappropriate dosing and
administration of morphine.
A 58-year-old man with chronic lower back pain is admitted to your unit with a PCA after a laminectomy.
His PCA orders read “morphine 2 mg every eight minute bolus with no basal dose.” He was taking Norco
(one tablet every six hours) at home for several months prior to the surgery. He is complaining of severe
pain, and you notice that his wife is pressing the button on the PCA. What is wrong with this picture?
Source: Northwestern Memorial Hospital Pain Expert Nurse Newsletter (November 2002).
• First, the bolus on a PCA should not be set at eight minutes. Remember that the peak effect of
most intravenous opioids is 15 minutes, so boluses given more frequently can lead to accumulation
of the drug and potential sedation. Eventually, such accumulation can lead to respiratory depression.
• Second, determine the patient’s previous opioid dose. Norco, or 10 mg of hydrocodone, is approximately
equal to 10 mg of oral morphine.The patient was taking four doses each day, or 40 mg,
which is approximately equal to 40 mg of oral morphine or 13.3 mg of parenteral morphine.Thus,
the best method of replacing his previous opioid dose would be to convert the 13 mg of parenteral
morphine into a basal rate of approximately 0.5 mg per hour. Contact your pharmacy for assistance.
• Third, to determine whether the bolus dose is correct, ask the patient how much relief he obtains
with the 2 mg. If the pain is relieved 100% and he is sedated, then reduce the bolus. If the pain is
relieved 100% and he is not sedated, the dose is correct. And if the relief is less than 100%, even
with the addition of the basal rate, then increase the bolus dose. Normally we use 50%–100% of
the hourly rate, which would be 0.25 mg–0.5 mg. But this dose only replaces his previous Norco
dose. Reassessment is critical to determine the effective dose.
• Fourth, educate the patient’s wife about the dangers of anyone other than the patient pushing the
button on the PCA pendant. Most family members or friends will be responsive. Consult the physician
and consider a care conference if they continue to interfere.
High-Alert Medications and Safe Practices: A study guide for nurses 7
Opioids
Nursing implications
Administration
• Opioids may be administered through a variety of routes: oral, transdermal, rectal, and parental
(which includes IV, subcutaneous (SQ), epidural, and intrathecal).
• Although some pain medications are prescribed to be administered intramuscularly, this method is
not recommended because the absorption is highly variable. Contact the physician to determine
alternative routes that may be available.8
• Prior to administration, assess baseline
- pain level
- sedation level
- respiratory status
• Verify established opioid use prior to initiating an opioid regimen.
• Assess for treatment contraindications, such as concomitant opioids that have the same duration
of action.
• Contact pharmacy regarding potential incompatibility concerns with IV analgesic medications.
• Assess the need for an appropriate bowel regimen to help prevent constipation.
Critical thinking
• Is the current regimen providing relief to the patient’s satisfaction?
• Does the patient or the patient’s family have misconceptions about opioid use? (e.g, fear of
addiction, tolerance, dependence, etc.)6
• Does the patient have unrealistic expectations of pain control?
• Does a pharmacist need to be consulted?
• Are there any new complaints or physical assessment changes that may relate to the use of
the pain medications?
• Is there an appropriate bowel regimen prescribed?
• Does the patient have undesirable past experiences with the use of opioids (e.g., effectiveness,
adverse effects, history of substance abuse, etc.)?7
• Are there concomitant orders for medications that contain acetaminophen? (If so, monitor
for total daily doses of acetaminophen.)
• If a PCA is ordered for a patient, is the patient a suitable candidate based on his or her level
of consciousness, psychological reasons, or intellectual capacity?
• All opioids are not equianalgesic. For example, 2 mg IV hydromorphone is approximately equal to
10 mg IV morphine.
• Opioids, even at appropriate doses, can suppress respiration, heart rate, and blood pressure.
Frequent monitoring is therefore essential.9
Monitoring
• Use a pain intensity scale to assess patient’s response to treatment. (For further guidance, refer to
Exhibit 1.1 on p. 12)
• Monitor “PRN” (as needed) use. Decreasing use may indicate decreasing pain, and orders may need
to be adjusted.10
• Monitor
- respiratory status
- sedation level
- nausea/vomiting
- bowel/bladder function
(For additional guidance on monitoring and assessing respiratory status and sedation level, use the
sample sedation scale and respiratory rate monitoring guidelines in Exhibit 1.2 on p. 13 for additional
guidance.)
• Monitor total daily acetaminophen intake for patients taking combination opioid products (e.g.,
patients with normal liver function should not receive greater than 4000 mg/day.) (To review the
aceteaminophen content of several common preparations, refer to Exhibit 1.3 on p. 14.)
• Dosing should be reevaluated if the cause or focus of the pain changes (e.g., postoperative, postprocedure,
etc.) or is removed (e.g., tubes, renal stones, etc.).
Oral opioids
• Sustained-release oral medications cannot be crushed or split.
• When reviewing medication orders, be vigilant for similar trade and generic names. For example,
• Oral liquid opioids are available in various concentrations, which can be stored in proximity to each
8 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Roxanol is morphine (immediate release, liquid)
Roxicodone is oxycodone (immediate release)
and
MS Contin is morphine (long-acting)
OxyContin is oxycodone (long-acting)
High-Alert Medications and Safe Practices: A study guide for nurses 9
Opioids
other. For example, Roxicodone is available in 5 mg/mL bottles or 20 mg/mL bottles.
• Be aware that potencies of IV and oral preparations are not equianalgesic. For example, 30 mg of
oral morphine is approximately equal to 10 mg IV/SQ morphine.
• Note products that combine an opioid and acetaminophen (refer to Exhibit 1.2 on p. 13):
- Norco contains hydrocodone 10 mg/acetaminophen 325 mg
- Vicodin contains hydrocodone 5 mg/acetaminophen 500 mg
• Watch for concomitant orders for acetaminophen, such as
- Tylenol Extra Strength, 1–2 tablets po every 6 hours PRN
- Norco, 1–2 tablets po every 4 hours PRN
• The total daily dose of acetaminophen should not exceed 4000 mg in patients with normal
liver function.
Transdermal opioids
• Remove old patches prior to placing new ones (when appropriate) on alternate sites (e.g., flat sites
such as the back or chest are best).
• Treat topical patches like any other medication: chart on the Medication Administration Record
when it was administered and on what site.11
• Medication from transdermal patches can be absorbed to a much greater extent in patients with
elevated body temperatures (e.g., from a warming blanket or fever).This can lead to significant
overdoses.12
PCA
• PCA infusions are always used in conjunction with a maintenance intravenous fluid.
• It is recommended that PCA cartridge concentrations be standard throughout an institution. For
example, only 1 mg/mL and 0.2 mg/mL are available for use. It is also recommended that colored
labels differentiate these concentrations. However, do not rely only on color to differentiate.
• The button should never be pushed by anyone else, including friends or family members.13
• Educate patients about the proper use of PCA before initiation. Start during the preoperative testing
visit so that patients are not too groggy to understand.14
• PCA tubing should be changed if there is a medication change or concentration change.
• The pump history should be cleared only if there is a medication change, such as morphine to
hydromorphone. If there is only a concentration change, such as hydromorphone 0.2 mg/mL to
hydromorphone 1 mg/mL, the history should not be cleared.
• It is recommended that two registered nurses check and verify the PCA pump settings at time of
initiation and/or change in dose, medication, concentration, or medication cartridge.
• Research shows that double checks are most effective when conducted independently.15
10 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
PCEA
• PCEA is contraindicated in patients receiving low molecular weight heparin or fibrinolytic therapy.
• No other medications should be infused through the epidural line.
• If a bolus dose is administered through the epidural catheter, the nurse should stay at the bedside
during and for five minutes following administration of the bolus dose.
• To avoid overdosing, the maximum bolus volume should not exceed the current hourly rate
of infusion.
• The epidural catheter may be left in place after discontinuing the infusion. A lock is placed at the distal
end of the catheter and does not need to be flushed.The epidural space is free space and is not
prone to clotting.
• It is recommended that two registered nurses check and verify the PCEA pump settings at the time
of initiation and/or change in dose, medication, concentration, or medication cartridge.
• Research shows that double checks are most effective when conducted independently.16
IV opioids
• Verify the concentration on the pharmacy label.
• Calculate the continuous infusion rate and independently check with another nurse or pharmacist.
• Never use a continuous infusion rate for acute pain of a limited duration.17
• When assessing the need for a possible change in the hourly continuous infusion rate, consider the
total usage (including number of bolus doses used) over at least the previous 12 hours. If only the
first few hours are considered, the need for an increase in the hourly rate may appear falsely elevated
as many times more boluses are required at the initiation of pain control medication until steadystate
is achieved.
• To prevent overdosing, bolus doses are preferred to increases in the hourly continuous infusion rate
to treat episodic or sporadic pain.18
Exercise
Your patient’s current pain medication orders are as follows:
Tylenol Extra Strength 1–2 tablets po every 6 hours PRN and Norco 1–2 tablets po every 4 hours PRN
It is 2100 and the patient has already received two tablets of Tylenol Extra Strength at 0100, 0700, and
1600 that day. He also has received Norco (two tablets at 1200 after physical therapy).The patient is now
requesting two more tablets of Norco before he goes to sleep. What should you do?
Answer provided on p. 57.
High-Alert Medications and Safe Practices: A study guide for nurses 11
Opioids
Summary points
• Errors associated with opioids are among the most commonly reported incidents that lead to
patient harm. Overdoses have occurred due to
- confusion between different opioids because of sound-alike names.
- anyone other than the patient pushing the button on the PCA or PCEA.
- the fact that even at appropriate doses, opioids can suppress respiration, heart rate, and
blood pressure. Frequent monitoring is therefore essential.
- failure to monitor total daily amounts of acetaminophen intake, which can lead to severe
liver damage.
• Independent double checks are recommended for rate calculations and infusion pump programming
so that errors can be identified prior to administration.
12 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Exhibit 1.1 Patient pain-assessment tool
• It is important to let your doctors and nurses know when you are in pain.
• Point to where the pain is located.
• Describe how the pain feels (e.g., aching, throbbing, or burning).There may be many ways to
describe your pain.
• Rate your pain on a scale of 0–10, with 0 meaning no pain and 10 meaning the worst pain
you could imagine.
Wong-Baker FACES pain rating scale
0 1 2 3 4 5 6 7 8 9 10
NO PAIN MODERATE PAIN WORST PAIN
Source:Wong D.L., Hockenberry-Eaton M.,Wilson D.,Winkelstein M.L., Schwarz P.:Wong’s Essentials of Pediatric Nursing ed. 6, St. Louis, 2001,
p. 1301. Copyright Mosby, Inc. Reprinted with permission.
High-Alert Medications and Safe Practices: A study guide for nurses 13
Opioids
Exhibit 1.2 Sedation scale and respiratory rate monitoring guidelines
Sedation scale
S Sleeping Normal sleep, respiration rate > 8 per minute
0 None Alert, awake
1 Mild Responds to normal voice
2 Moderate Responds to loud voice/shaking
3 Severe Somnolent, difficult to arouse
Sensory motor checks
Patient-controlled analgesia (PCA)
Sedation scale and respiratory rate:
every two hours for 24 hours, then every
four hours thereafter.
Epidural and patient-controlled
epidural analgesia (PCEA)
Sedation scale and respiratory rate:
every two hours for 24 hours, then every
four hours thereafter.
Same monitoring frequency following initiation
of epidural infusion, after a bolus,
and/or increase in rate.
If bupivacaine is used, check lower extremities every two hours, while awake, for the first 24
hours.
0 Normal strength and sensation
1 Weak but able to bend knees and ankles, normal sedation
2 Unable to bend knees, normal sensation
3 Unable to move legs, decreased sensation
• Monitor blood pressure every hour for four hours, then every four hours thereafter
• Check orthostatic blood pressure prior to ambulating
14 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Exhibit 1.3 Acetaminophen hepatoxicity
It is necessary to monitor the total acetaminophen intake for patients taking combination opioid
products.The oral adult analgesic dose of acetaminophen is 325 mg–1000 mg.The total daily dose
should not exceed 4000 mg. Recognition of the quantities of acetaminophen provided by various
combination analgesic products can help to prevent unintended ingestion of potentially toxic doses.
The following table details the acetaminophen content of several common preparations.
1Although effective for many types of moderate to severe pain, combination agents have a maximum or ceiling dose
due to the acetaminophen.Thus,Vicodin Extra Strength® and Darvocet N-100® are not recommended, as their
acetaminophen content is high.
It is best to use only one of these agents at a time. When these agents are prescribed at close to
the maximum acetaminophen dose, it is necessary to inform patients not to use acetaminophen
containing over-the-counter (OTC) analgesics, sinus/allergy medicine, or cough-cold remedies.
Source: Reprinted with permission from Michael Fotis, M.A. (Ed). Optimizing medication use at NMH: Suggested guidelines for commonly
encountered problems. Chicago: Northwestern Memorial Hospital, 2003.
TRADE NAME
Vicodin®
Vicodin Extra Strength®1
Darvocet N-100®1
Norco®
Tylenol®
Tylenol Extra Strength®
Tylenol #3®
Tylenol #4®
Percocet-5/325®
ACETAMINOPHEN
CONTENT
500 mg
750 mg
650 mg
325 mg
325 mg
500 mg
300 mg
300 mg
325 mg
NUMBER OF
TABLETS/CAPSULES
TO REACH 4 G/DAY
8
5
6
12
12
8
13
13
12
OPIOID
Hydrocodone 5 mg
Hydrocodone 7.5 mg
Propoxyphene 100 mg
Hydrocodone 10 mg
Not applicable
Not applicable
Codeine 30mg
Codeine 60 mg
Codeine 5 mg
High-Alert Medications and Safe Practices: A study guide for nurses 15
Opioids
References
1. M.R. Cohen and C.M. Kilo. “High-alert medications: Safeguarding against errors.” In M.R. Cohen (Ed.),
Medication Errors.Washington, DC: American Pharmaceutical Association, 1999.
2. Ibid.
3. Ibid.
4. Ibid.
5. “Safety issues with patient-controlled analgesia.” Huntingdon Valley, PA: Institute for Safe Medication
Practices (ISMP), 2003 July 10.
6. M. Fotis, M.A. (Ed.) Optimizing medication use at NMH: Suggested guidelines for commonly
encountered problems. Chicago: Northwestern Memorial Hospital, 2003.
7. Ibid.
8. J. Paice. “Alternative to intramuscular pain medication.” Northwestern Memorial Hospital Pain Expert
Nurse Newsletter. 2003 January.
9. “More on avoiding opiate toxicity.” Huntingdon Valley, PA: ISMP, 2002 May 29.
10. See note 6 above.
11. “Serious consequences if patches are not removed.” Huntingdon Valley, PA: ISMP, 2003 June 26.
12. “Elevated skin and body temperatures.” Huntingdon Valley, PA: ISMP, 2003 June 30.
13. “Safety issues with patient-controlled analgesia.” Huntingdon Valley, PA: ISMP, 2003 July 10.
14. See note 8 above.
15. “Maybe Santa’s on to something.” Huntingdon Valley, PA: ISMP, 2001 December 12.
16. Ibid.
17. See note 6 above.
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Nursing Study Guide
TARGET Diabetes Nursing Study Guide
Published: 01/2006
Copyright 2006 by MaineHealth. All rights reserved. The material contained in this publication may be
displayed, copied, distributed or downloaded for personal or noncommercial uses, provided such materials
are not altered or modified and a reference to MaineHealth is provided.
Inquiries regarding specific permissions should be directed to:
Kristina M. Scrutchfield
TARGET Diabetes Program Manager
MaineHealth
465 Congress Street, Suite 301
Portland, ME 04101
Phone: (207) 541-7534
Fax: (207) 541-7540
Email: scrutk@mmc.org
This publication and the materials and information contained herein have been produced for informational
purposes as a service to patients, their families, and the general public and are provided “as is” without a
warranty of any kind, either express or implied. MaineHealth shall not be liable for direct, indirect, special,
incidental or consequential damages related to the user’s decision to use this publication or any material or
information herein.
TARGET Diabetes Nursing Study Guide
1
Table of Contents
I. INTRODUCTION...........................................................................................I-1
A. Contributors ....................................................................................................................... I-1
B. Objectives........................................................................................................................... I-2
C. What is the TARGET Diabetes Program?........................................................................ I-3
D. What is MaineHealth?........................................................................................................ I-3
II. DIABETES ...................................................................................................II-1
A. What is Diabetes?............................................................................................................. II-1
1. Diagnosis .................................................................................................................................... II-2
2. Types of Diabetes...................................................................................................................... II-2
3. Risk Factors ............................................................................................................................... II-3
III. CHRONIC COMPLICATIONS.....................................................................III-1
A. How to Prevent Complications....................................................................................... III-1
IV. TREATMENT ............................................................................................. IV-1
A. Meal Planning...................................................................................................................IV-1
B. Physical Activity ..............................................................................................................IV-2
1. Problem-Solving for Barriers to Activity.................................................................................IV-4
2. Testing Blood Glucose and Activity .......................................................................................IV-5
3. Hypoglycemia............................................................................................................................IV-5
C. Methods Used to Monitor Diabetes Control..................................................................IV-6
1. Tests for Glycemia ...................................................................................................................IV-6
2. Self Monitoring of Blood Glucose...........................................................................................IV-7
D. Oral Medication Therapy...............................................................................................IV-11
E. Insulin Basics.................................................................................................................IV-12
1. Type..........................................................................................................................................IV-12
2. Concentration..........................................................................................................................IV-13
3. Purity ........................................................................................................................................IV-13
4. Sources....................................................................................................................................IV-13
F. Insulin Pumps ................................................................................................................IV-13
G. Insulin Guidelines and Pens.........................................................................................IV-14
TARGET Diabetes Nursing Study Guide
2
H. Incretin Mimetics............................................................................................................IV-14
V. ACUTE COMPLICATIONS ......................................................................... V-1
A. Hypoglycemia (Low Blood Glucose) ..............................................................................V-1
1. Symptoms................................................................................................................................... V-1
2. Causes ........................................................................................................................................ V-1
3. Treatment ................................................................................................................................... V-2
4. Prevention................................................................................................................................... V-3
5. Medic-Alert Identification .......................................................................................................... V-3
B. Hyperglycemia (High Blood Glucose) ............................................................................V-3
1. Symptoms................................................................................................................................... V-3
2. Causes ........................................................................................................................................ V-4
3. Treatment ................................................................................................................................... V-4
4. Prevention................................................................................................................................... V-4
C. Diabetic Ketoacidosis (DKA) ...........................................................................................V-4
1. Symptoms................................................................................................................................... V-5
2. Causes ........................................................................................................................................ V-5
3. Treatment ................................................................................................................................... V-5
4. Prevention................................................................................................................................... V-6
D. Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS)..................................V-6
1. Symptoms................................................................................................................................... V-6
2. Causes ........................................................................................................................................ V-6
3. Treatment ................................................................................................................................... V-6
4. Prevention................................................................................................................................... V-7
E. Sick Day Guidelines .........................................................................................................V-7
1. What Patients Should Do When Ill:......................................................................................... V-7
2. Prevention................................................................................................................................... V-8
VI. STRESS AND DIABETES ......................................................................... VI-1
A. Sources of Stress ............................................................................................................VI-1
B. Getting a Handle on Stress.............................................................................................VI-1
C. Depression and Diabetes................................................................................................VI-2
D. Diabetes and the Family..................................................................................................VI-3
VII. THE CHANGE PROCESS................................................................... VII-1
A. Goal Setting Example.....................................................................................................VII-1
B. Behavior Change Goals .................................................................................................VII-2
1. Long-Term Goals.....................................................................................................................VII-2
2. Short-Term Goals....................................................................................................................VII-3
3. Acceptable Goals ....................................................................................................................VII-4
TARGET Diabetes Nursing Study Guide
3
C. Diabetes Educators ........................................................................................................VII-4
VIII. DIABETES AND PREGNANCY ......................................................... VIII-1
A. Preconception Visit ..............................................................................................VIII-1
IX. TESTING AND COMPETENCIES.............................................................. IX-1
A. Diabetes Study Guide Pretest/Post test ........................................................................IX-1
B. Diabetes Study Guide Pretest/Post test (Answer Key) ................................................IX-5
C. Insulin Injection Competency.........................................................................................IX-9
D. Hypoglycemia Competency..........................................................................................IX-10
E. Glucometer Competency ..............................................................................................IX-11
F. Monofilament Competency...........................................................................................IX-12
G. Insulin Pen Competency ...............................................................................................IX-13
X. APPENDIX .................................................................................................. X-1
A. Diabetes Summary ...........................................................................................................X-1
B. Pre-Diabetes......................................................................................................................X-1
C. References.........................................................................................................................X-1
D. More Information...............................................................................................................X-1
XI. END NOTES............................................................................................... XI-1
TARGET Diabetes Nursing Study Guide
I-1
I. INTRODUCTION
A. Contributors
We would like to thank the following individuals for their interest, input, and support in
developing this study guide:
Stephan Babirak, MD The Maine Center for Diabetes Sandy Barth, RN, BSN, CDE Miles Memorial Hospital Kathleen Beers, RN, BSN, CDE Mercy Hospital Pauline A. Bergeron Flood, BS MaineHealth
Donna Bolstridge, RN, BSN Home Health Visiting Nurses of Southern Maine Kay Mullin, RD, LD, CDE The Maine Center for Diabetes Bonnie Quint, RN, BSN, CDE Houlton Regional Hospital Kris Scrutchfield, RT(R)(CV) MaineHealth Pat Watson, RD, MS, CDE Stephens Memorial Hospital Cindy Young, RN, C, CDE The Maine Center for Diabetes Susan Young, RN, BSN, CDE Blue Hill Memorial Hospital Written and Edited by: Tracy Callahan, RN, MSN, CDE The Maine Center for Diabetes
Laura Gordon, RN, BSN, CDE Maine Medical Center – Physicians Health Organization
Mary McDonough, RN Maine Medical Center Family Practice Center TARGET Diabetes Nursing Study Guide
I-2
B. Objectives
This study guide was developed by the TARGET Diabetes Program at MaineHealth to
provide a basic overview of diabetes for registered nurses, licensed practical nurses,
medical assistants, and any other clinical person who feels they could benefit. Included is
a pretest & posttest as well as competencies for:
• Injecting insulin
• Treating hypoglycemia
• Glucometer instruction
• Use of insulin pens
• Monofilament testing
By reading this study guide and completing the post test and competencies, you should be
able to:
• Describe generally what diabetes is, how it is diagnosed, who is at risk, and how it
is treated.
• State the symptoms, causes, treatment, and prevention of hypoglycemia,
hyperglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic nonketotic
syndrome.
• Identify the potential chronic complications that can occur due to diabetes.
• State how patients should care for themselves in general as well as when ill, under
stress, and during pregnancy.
Once you have completed reading this study guide, go to:
http://www.surveymonkey.com/s.asp?A=68915169E36695
to do a brief evaluation of this learning tool.
Feel free to copy and share sections with your patients such as the blood glucose log,
self-care action plan, activity suggestions, goal setting, sick day foods, insulin pen use,
and guidelines for the use of insulin.
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C. What is the TARGET Diabetes Program?
The TARGET Diabetes Program is a program offered by MaineHealth to improve care
and outcomes for people with diabetes. The goals of the program are to:
• Promote effective diabetes patient education and self-management skills for
Maine adults and their families.
• Promote public awareness of diabetes as a common, serious, and preventable
medical illness.
• Support doctors and nurses in providing high quality care to people with diabetes.
• Promote healthy lifestyles and activities that help prevent diabetes and its’
complications.
D. What is MaineHealth?
MaineHealth is a nonprofit health care system that includes Maine Medical Center, eight
community hospitals, and other health care organizations in the ten counties of southern
central and western Maine. The mission of MaineHealth is “working together so our
communities are the healthiest in America.” In addition to providing the highest quality
medical care possible, MaineHealth actively supports community health improvement
through programs like TARGET Diabetes.
For more information about diabetes, the TARGET Diabetes Program, and MaineHealth,
please check out our website at www.mainehealth.org and click on Health Information
then click the Diabetes link or you can contact:
Kristina M. Scrutchfield, RT(R)(CV)
TARGET Diabetes Program Manager
MaineHealth
465 Congress St., Suite 301
Portland, ME 04101
Phone: (207) 541-7534
e-mail: scrutk@mmc.org
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II. DIABETES
A. What is Diabetes?
“Diabetes Mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action, or
both”1
The pancreas has two functions. It secretes pancreatic juices which help us to digest our
foods and it secretes hormones that control body processes. Insulin is a hormone
produced by the beta cells in the pancreas whose chief function is to help the body’s cells
take in blood glucose. The carbohydrate in foods we eat is largely broken down into
glucose. Glucose is absorbed into the bloodstream and delivered to the cells where it is
used for energy or it is stored for energy use later.
Blood glucose levels rise immediately after eating. In response to this rise in glucose, the
pancreas secretes insulin. The cells have receptor sites for insulin. Insulin acts like a key
to the cell. Once insulin attaches, it opens the cell so that glucose can enter. By doing
so, the cell receives energy and the glucose levels in the bloodstream decrease. Diabetes
is caused by the body’s failure to make insulin or properly use the insulin it does make.
The symptoms exhibited by patients with diabetes are connected to the body’s attempt to
correct what it senses as abnormal, in this instance, hyperglycemia. The following are
the “classic symptoms of diabetes”:
• Polyuria – The kidneys are working extra hard to remove the excess
glucose from the bloodstream through the urine.
• Polydipsia – When the body releases extra glucose into the urine, it pulls
water with it, thus causing dehydration and the symptom of increased
thirst. Drinking more also allows the kidneys to filter more glucose.
• Polyphagia – If cells are not receiving enough glucose for normal
functioning they end up hungry! This is also why patients report fatigue,
weakness and weight loss.
• Blurred vision – Changes in vision frequently occur. This change is due
to extra glucose in the bloodstream. When glucose levels are high,
glucose pulls water with it. The combination causes swelling in the lens
and a distortion in the vision.
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1. Diagnosis
Diagnosis for diabetes may be done through the following methods:
• Fasting Plasma Glucose – A blood sample is taken 10-12 hours after the
previous meal (generally first thing in the morning before breakfast). Values
> 126 are diagnostic for diabetes.
• Casual Plasma Glucose Test – A random blood glucose level taken any time of
day regardless of when the last meal occurred. Values > 200 mg/dl with “classic”
symptoms are diagnostic for diabetes.
• Oral Glucose Tolerance Test (OGTT) – After a 10-12 hour fast, a blood glucose
sample is taken. A 75 gm glucose solution is given to the patient. After two
hours, another blood glucose sample is taken. Values > 200 mg/dl are diagnostic
for diabetes.
• Pre-Diabetes – Diagnosis for a condition preceding diabetes, known as Pre-
Diabetes is determined by:
-- Fasting Plasma Glucose (see above) – Reveals blood glucose level
between 100-125 mg/dl.
-- Oral Glucose Tolerance Test (OGTT) (see above) – Blood glucose levels
> 140 mg/dl but < 200 mg/dl.
All tests need to be repeated to confirm diagnosis.2
2. Types of Diabetes
The two most common types of diabetes are type 1 and type 2. In type 1 diabetes, the
pancreas makes little or no insulin. In fact, within 10 years most persons with type 1
diabetes will no longer be making any insulin at all. People with type 1 diabetes are
prone to developing ketosis which is discussed at length in the ‘acute complications’
section. People with type 1 diabetes need insulin shots in order to live. Type 1 diabetes
can begin at any age, but usually occurs before age 30.
In type 2 diabetes, the pancreas may produce more insulin than usual, but the cells are
unable to use it. Food is broken down in the normal way; however, three areas important
to how we process the glucose supplied by our food are affected. The first is the liver. It
normally stores excess glucose for when our bodies need it, such as during exercise or
missed meals. With type 2 diabetes, the liver becomes overactive due to hormones and
spills glucose into the bloodstream. Second are the cells themselves. Typically the cells
should grab onto the insulin, open up and allow the glucose in. With diabetes, the cells
are resistant and unable to use the insulin efficiently. This is due in large part to lifestyle
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issues such as obesity which creates fatter cells, as well as inactivity, and genetics. This
is referred to as ‘insulin resistance’. Third, we now know that the beta cells of the
pancreas decline over the years. So, the longer a person lives with type 2 diabetes, the
increased chance he/she has that their body will need pharmacological help to do the
same work it does now. Glucose builds up in the bloodstream instead of entering the
cells for these reasons.
Changes in lifestyle are the most effective way to deal with type 2 diabetes. Regardless if
this is a new diagnosis or a patient who has had it for many years, meal planning and
exercise are the key tools used to control blood glucose levels. The onset for type 2
diabetes is more common over the age of 40 but can occur at any age. In fact, we are
now seeing it in the pediatric population.
Gestational diabetes occurs during pregnancy. The hormones released during
pregnancy cause the mother to develop ‘insulin resistance’, similar to type 2 diabetes.
This usually resolves after delivery of the baby. It is however, a risk factor for
developing type 2 diabetes in the future.
3. Risk Factors
Type 1 diabetes is an auto-immune disease. This means the body begins to recognize
the beta cells (the insulin producing cells) in the pancreas as foreign substances and
begins to develop antibodies to them, thus eventually destroying them and their ability to
produce insulin. There are several theories as to the actual pathology of type 1 diabetes,
however the most common idea is that people have the genetic pre-disposition to
developing it. The person comes into contact with an environmental or genetic trigger
(virus) and this begins the destruction of the beta cells.
Type 2 diabetes results from a combination of risk factors. Genetics and ethnic
background (Native Americans, Hispanic Americans, and African Americans have a
higher incidence of type 2 diabetes) predispose patients to a greater risk. Other factors
are being overweight, > 30 years of age, having a baby >9 pounds, and having a history
of gestational diabetes or prediabetes.
Stress, illness or surgery, and certain medications such as steroids, can aggravate diabetes
and make it more difficult to control. Chronic pancreatitis and pancreatic cancer
resulting in the partial or total removal of the pancreas can also lead to diabetes.
Diabetes is a serious, lifelong condition. The majority of what it takes to control blood
glucose levels is done by the patient (> 99%).3 Some days glucose levels are great and
the next day not so great; there are degrees of control. It is important to communicate
that diabetes never goes away! Living with diabetes is a lot of work. New skills are
required to learn about the disease and what steps can be taken to control it. Changing
lifestyle habits by becoming more active, learning how to eat healthy and to control stress
will help a person live a full, healthy and productive life.
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III. Chronic Complications
Diabetes can lead to serious, long-term complications. Eyes, feet, kidneys, nerves, heart and blood
vessels, as well as other parts of the body can be affected. The primary contributors to the
development of complications are: 1) high blood glucose levels; 2) high blood pressure; and
3) high blood fats. The potential results of these three factors are: 1) diminished or blocked blood
flow; 2) damage to the blood vessels; and 3) nerve destruction. Below are listed potential
complications:
• Heart & Blood Vessel Disease
Heart attack
Stroke
Peripheral Vascular Disease
Note: Cardiovascular Disease is the major cause of mortality for individuals with diabetes. It
is also a major contributor to morbidity and the direct and indirect costs of diabetes.
• Eye Disease
Retinopathy
Cataracts
Glaucoma
• Nephropathy
Kidney disease – unable to excrete urine by the kidneys.
• Neuropathy
Sensory
Burning, numbness, poor coordination in feet, legs, hands and arms
Note: Footcare tip sheet is located in the back of this section.
Autonomic
Damage to organs that function without conscious thought:
stomach, heart, blood pressure, intestines/bowels, bladder, skin & sex
organs
• Other
Mouth – tooth decay, thickening of blood vessels, gum disease
Decreased immune system functioning
Skin – increased infections
A. How to Prevent Complications
The Diabetes Control and Complications Trial (DCCT) is a clinical study that was conducted from
1983 to 1993 by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
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The study showed that keeping blood glucose levels as close to normal as possible slows the onset
and progression of eye, kidney, and nerve diseases caused by diabetes. In fact, it demonstrated
that any sustained lowering of blood glucose helps, even if the person has a history of poor control.
Note: DCCT article is in the back of this section.
At each visit ask patients about any new or continuing symptoms they may be having such as pain
or lack of sensation in their extremities, changes in vision, frequent infections, slow healing of cuts
and sores, fatigue, shortness of breath, or chest pain. Encourage your patients to see a provider to
evaluate sores or symptoms as soon as they arise. DO NOT WAIT!!! Early detection is the key to
prevention.
The American Diabetes Association (ADA) publishes Standards of Care each year.
This is a list of what each person with diabetes needs to do in an effort to prevent complications.
The ADA provides guidelines for lab tests with corresponding “acceptable levels” as well as
patient directed actions. These guidelines help providers and patients focus on early detection and
prevention of complications. Guidelines are also provided for the treatment of high blood
pressure, high blood fats, and high blood glucose levels. Become familiar with these guidelines by
visiting the ADA website at www.diabetes.org. Share what you learn with your patients since, as
previously stated, it is estimated that > 99% of care provided to a person with diabetes, they
provide themselves.
General guidelines are:
• Hemoglobin A1c every 3-6 months
• Weight every visit (also should monitor at home)
• Blood Pressure check every visit
• Foot Check every visit (patient to check feet at home daily)
• Fasting Lipid Profile yearly
• Albumin/Creatinine Ratio yearly
• Flu Shot yearly
• Dentist yearly (brush & floss daily)
• Pneumovax
• Aspirin Therapy (unless contraindicated)
Note: Current year guidelines and monofilament information are in the back of this section.
The Bottom Line:
• Control Blood Glucose Levels!
• Control Blood Pressure!
• Control Blood Fats!
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Risk Factor Goal Frequency Why is it important?
Blood Pressure Less than 130/80 Every visit High blood pressure can cause kidney
damage and strokes.
Hemoglobin A1c Less than 7% Every 3 months Checks for control of blood glucose
levels over the past 2-3 months.
Low-Density Lipids
(LDL)
Less that 100 mg/dl
(If Cardiovascular Disease is
noted, less than 70 mg/dl is
optional)
Yearly
(more often if
needed to achieve
goal)
Checks for “bad” cholesterol. High LDL
can cause heart disease and strokes.
High-Density Lipids
(HDL)
Greater than 40 mg/dl
for men
Greater than 50 mg/dl
for women
Yearly
Checks for “good” cholesterol. Helps
keep “bad” cholesterol from building up
in the arteries.
Triglycerides Less than 150 mg/dl Yearly
A form of fat in your blood that can
raise your risk of heart disease. Value
can be elevated if the blood glucose
level is out of control.
Cholesterol Less than 200 mg/dl Yearly Used to estimate your risk of
developing heart disease.
Urine
Albumin/Creatinine
Ratio
Less than 30 ugALB/mgCR Yearly Checks for protein in urine, a sign of
early kidney damage.
Aspirin For patients over 40 yrs old
Each Day
(unless otherwise
indicated)
Prevents cardiovascular events.
Comprehensive Foot
Exam Healthy feet Yearly
Checks circulation, nerves, and skin. It
can prevent amputations.
*Patients are also encouraged to do a
foot check each day at home.
Dilated Eye Exam No retinal changes Yearly Checks for eye damage from diabetes,
can prevent blindness.
Influenza Flu shot Yearly Prevents a more severe form of the flu.
Pneumonia Pneumovax vaccine Discuss with
your doctor Prevents pneumonia.
BMI
(Body Mass Index) Less than 25 Every visit
Body Mass Index is a measure of weight
compared to height which relates to the
amount of body fat a person has.
Smoking Cessation
To quit smoking
The Maine Tobacco Helpline:
1-800-207-1230
Discuss at every
visit. Decreases premature death.
Teeth Cleaning and exam Every 6 months Prevents tooth and gum disease.
American Diabetes Association
Guidelines to Prevent
Complications from Diabetes
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Take Care of Your Feet for a Lifetime
Take care of your diabetes.
• Work with your health care team to keep your blood sugar within a good range.
Check your feet every day.
• Look at your bare feet everyday for cuts, blisters, red spots and swelling.
• Use a mirror to check the bottoms of your feet or ask a family member for help if you
have trouble seeing.
Wash your feet every day.
• Wash your feet in warm, not hot, water everyday.
• Dry your feet well. Be sure to dry between the toes.
Keep the skin soft and smooth.
• Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between
your toes.
Smooth corns and calluses gently.
• Use a pumice stone to smooth corns and calluses.
• Don’t cut corns or calluses yourself.
Trim your toenails each week or when needed.
• Trim your toenails straight across and tile the edges with an emery board or nail file.
• Trim after bathing when the nails are softer.
• Don’t cut into the corners of the nails.
Wear shoes and socks at all times.
• Never walk barefoot.
• Wear comfortable shoes that fit well and protect your feet.
• Stop wearing shoes that cause irritations.
• Feel inside your shoes before putting them on each time to make sure the lining is
smooth and there are no objects inside.
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Protect your feet from hot and cold.
• Wear shoes at the beach or on hot pavement.
• Wear socks at night if your feet get cold.
Keep the blood flowing to your feet.
• Put your feet up when sitting.
• Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day.
• Don’t cross your legs for long periods of time.
Be more active.
• Plan your physical activity program with your doctor.
Check with your doctor.
• Have your doctor check your bare feet and find out whether you are likely to have
serious foot problems. Remember that you may not feel the pain of an injury
• Call your doctor right away if a cut, sore blister, or bruise on your foot does not begin
to heal after one day.
• Follow your doctor’s advice about foot care.
Get started now.
• Set a time every day to check your feet.
• Begin taking good care of your feet today!
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Date:_________________
Patient name:______________________________________________ D.O.B._______________
Physician:___________________________________________ Diabetes Type : 1 2 (circle one)
Diabetes complications: ○ Peripheral neuropathy ○ Amputation: _________________ ○ Nephropathy
Smoker? Y N
1) Foot evaluation:
Fill in blanks with “Y” or “N” and indicate “Right” or “Left” foot Right Foot Left Foot
Is there a current ulcer or history of a foot ulcer?
Are there any changes in the foot since the last evaluation?
If yes, circle type of change: swelling / abnormal shape / elevated skin temp
Are there any deformities of the toes?
Are the toenails thick, too long, ingrown, or infected with fungal dx?
Is there any evidence of muscle weakness or foot drop?
Are the pulses present? Circle : posterior tibial / dorsalis pedis
Does the patient have properly fitting footwear?
Does the patient demonstrate appropriate foot care?
4) Risk categorization
Low risk includes all of the following: no amputation, no prior foot ulcer, no deformity, pedal pulse
present, intact protective sensation
High risk includes one or more of the following: prior amputation, history of foot ulcer, foot
deformity, absent pedal pulses, loss of protective sensation
5) Management
Referral made to: □ Podiatrist □ Vascular surgeon □ Foot surgeon □ Orthotist □ Vascular lab
□ Diabetes educator □ Endocrinologist □ Rehab specialist □ Other:__________________
Footwear recommended: □ None □ Athletic shoes □ Inserts □ Custom shoes □ Depth shoes
If smoker: □ cessation counseling provided □ referred to cessation counselor □ cessation meds prescribed
Schedule follow up foot exam in ____________ (mos)
Note: High risk patients should have foot exam at every visit. (Adapted from “Feet Can Last a Lifetime”(NDEP))
3) Foot assessment
Measure, draw in, and label
patient’s skin condition, using the
key below and foot diagram at left.
C= callus R= redness
U = ulcer S = swelling
PU= pre-ulcer W = warmth
F= fissue D= dryness
M= maceration
2) Sensory Foot Exam
Label sensory level with "+" in the
five circled areas of the foot if
patient can feel the monofilament
and "-" if they cannot. See nest
page or instructions on
monofilament use.
TARGET Diabetes Comprehensive Foot Exam
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III-7
Use of the Monofilament
How the monofilament works:
1) The filament applies 10 grams of pressure to a small point on the skin.
2) The filament is calibrated to bend when the 10 grams of force has been applied.
3) If the patient does not feel the monofilament when you apply pressure to bend it, sensation loss has
occurred in that area.
Who should the monofilament be used with?
• All patients with diabetes should have a filament test done at least annually.
• The American Diabetes Association (ADA) and the Bureau of Primary Health Care’s (BPHC)
Lower Extremities Amputation Program (LEAP) recommend visual foot
exams/inspections at each visit.
• You may request a supply of up to 50 free monofilaments by filling out the Free
Monofilament Form at: http://bphc.hrsa.gov/leap/ordering_leap_filaments.htm
How to use the monofilament
1) Show monofilament to patient. Demonstrate that it does not hurt.
Touch their hand / arm with monofilament.
2) Have patient turn head, close eyes, or look at the ceiling.
3) Ask patient to inform you when they feel the monofilament touching their foot.
4) Hold monofilament perpendicular to the skin and use 3 second sequence
a) touch the skin at the areas indicated on the adjacent diagram
b) filament bends
c) lift from the skin
5) Do not use rapid movement
a) Use in random sequence
b) If client does not say yes when a certain area is touched, continue in your
sequence. After you have completed, return to the area assessed as poor and
repeat the test.
Care of a non-disposable (durable) monofilament
1) The filament will last indefinitely if returned to its plastic case.
2) Cleaning the filament should be done between patients using sodium hypochlorite (household
bleach 1:10).
Education plays a major role in preventing amputations and serious problems with feet and legs!!!!!
To obtain a copy of the TARGET Diabetes provider foot exam worksheet or a foot check reminder
poster (compliments of the Maine Diabetes Control Program) for your waiting room, see the TARGET
Diabetes Program information on the MaineHealth website at www.mainehealth.org.
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IV. TREATMENT
It is important to note here that hyperglycemia can prevent people from being motivated
to care for themselves. Lowering glucose levels with the help of oral medications or
insulin initially can get them feeling better faster and thus more motivated to begin and
maintain an exercise program, healthy eating habits, self monitoring of blood glucose
levels, taking prescribed medications, and other self-care activities.
A. Meal Planning
What people eat affects their overall health; including their weight, blood glucose control
and lipid profile. People who have diabetes are still regular people with normal
nutritional needs. A healthy eating diet that promotes normal growth and development
and meets all the nutrient needs remains the basis of the diet. However, because of the
need for good blood glucose control as well as fat control, additional dietary principles
need to be understood. Understanding one’s own eating choices and behaviors is crucial
to learning a healthy eating pattern for people with diabetes.
The major nutrients in food are: carbohydrates, proteins, fats, vitamins, minerals, and
water. There are three energy yielding nutrients: carbohydrates, proteins, and fats. The
body needs all of these in different amounts for good nutrition. One hundred percent of
carbohydrates breakdown to glucose; 50% of protein and less than 10% of fat are
converted to glucose.4
Glucose is the body’s main energy source and therefore the majority of the calories we
need to eat come from carbohydrates; approximately 45-65%.5 Insulin allows glucose to
enter into the muscle cell where it is used for energy. Balancing food, exercise, and
diabetes medication is essential for good diabetes control. Individuals need to pay close
attention to the amounts and timing of the foods they eat that are high in carbohydrates
since these have the greatest affect on blood glucose levels. A healthy eating plan needs
to be promoted to help with normal nutritional needs including normal growth and
development as well as weight control and heart health.
In type 1 diabetes injected insulin needs to be balanced with food. Since the person does
not make any insulin, blood glucose levels can rise rapidly if they do not have enough
insulin to cover a meal. With type 2 diabetes the ability to get glucose into the cells
slows down over time (insulin resistance) and the pancreas decreases its production of
insulin, often due to age, genetics, or weight gain.
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To prevent the body from becoming overwhelmed with glucose resulting in
hyperglycemia, there are a few basic guidelines you can teach your patients:
• Limit food portions at each meal or snack
• Divide food into 3 evenly spaced meals
• Aim for consistency in meal times
• Avoid skipping and/or delaying meals
• Consume mostly calorie free beverages
• Include foods from all food groups everyday
Tips to control portion sizes:
• Use a smaller plate
• Put utensils down between bites
• Encourage mealtime conversation
• Do not return for seconds
• Weigh & measure foods to learn appropriate serving sizes
Suggested visual teaching method for patients:
Demonstrate to patients how to divide their plate into acceptable portions. For
lunch and dinner divide the plate into ¼ carbohydrate, ¼ protein, and ½
vegetable. Breakfast is a bit more of a challenge since most of the choices are
carbohydrates. Therefore, encourage less juices and the addition of protein and
fiber (e.g. whole wheat toast with peanut butter, toasted almonds on cereal) which
helps to regulate blood glucose.
A dietitian can help patients to understand how their favorite foods can be worked into
their meal plan.
B. Physical Activity
Physical activity of any kind will help to lower blood glucose levels. Activity moves
glucose into cells, increases the sensitivity of cells to insulin, and increases the absorption
rate of insulin. All patients with diabetes should be encouraged to be as active as
possible. In addition to lowering blood glucose, physical activity helps to:
• Increase bone density and prevent osteoporosis
• Increase metabolism
• Control weight
• Relieve stress
• Boost mood, promote sleep
• Improve flexibility, joint range of motion & balance
• Improve muscle tone
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• Improve reflexes to decrease falls
• Improve cardiovascular health
• Create a sense of community or feeling of belonging
• Provide a sense of well-being
• Lower or control blood pressure
• Lower triglycerides “bad” cholesterol
• Raise HDL “good” cholesterol
The goal for everyone is to be active at least 30 minutes per day or more. During
exercise people should be able to talk in short sentences but not necessarily sing. Patients
should be encouraged to talk with their physician before starting an exercise program to
be sure the activity they wish to participate in will be safe for them. Patient teaching
includes:
• Wearing proper shoes to prevent foot problems – break new shoes in slowly.
• Drinking plenty of fluids.
• Not “over exercising”; start slowly and increase the length of time an activity is
done or the number of times it is done each week.
• Carrying a carbohydrate containing source (for example: glucose tablets,
crackers, or juice) if taking oral diabetes medications or insulin.
• Reviewing signs and symptoms of a heart attack which are: chest pain/pressure,
diaphoresis (sweating), shortness of breath, jaw pain, left arm/shoulder pain, back
pain and nausea. Also, review how to get immediate help.
It can be difficult to get people moving! At each visit reward any and all efforts patients
have made toward improving their activity level. Activity is one of the most important
tools a person can use to help control their diabetes. If you are having difficulty getting
any of your patients moving, consult the following list for ideas on how to problem-solve
the barriers your patients may present as reasons for not engaging in more activity.
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1. Problem-Solving for Barriers to Activity
a. No Time
• Get up earlier/go to bed later.
• Combine activities (playing with children, housework, dancing).
• Schedule it into your day (make a date with yourself).
• Take the stairs instead of the elevator.
• Break it into several short sessions per day.
b. Weather (Too hot! Too Cold! Too Rainy! Too Snowy!
Too Windy…)
• Walk on an indoor track (check the local high schools or colleges).
• Use exercise videos or TV programs.
• Join a fitness center or gym.
• Buy home exercise equipment.
• Get some all weather gear and get outside! (be careful of icy
weather!!!!)
c. Medical Conditions
• Talk with the physician about a physical therapy consult and/or
medications that might make activity more comfortable.
• Try warm water pool exercises.
• Suggest arm chair exercises.
• Patients with heart disease, hypertension, or diabetes complications
such as neuropathy and retinopathy require individual activity
programs that take these conditions into consideration and should be
discussed with a physician.
d. No Energy!
• Start small!! Make small achievable goals and increase as able.
• Exercise will give you energy….really it will!
e. Too Expensive
• Check with insurance companies, some cover a portion of membership
cost if you prove you attend a minimum number of times each month.
• Take out exercise videos from the library.
• Walking is cheap and you can do it anywhere!
• Look for exercise equipment at yard sales.
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f. Boring / No Motivation
• Choose activities that will be fun (sight seeing, museum tour, ice
skating, roller skating, bowling, swimming, etc).
• Exercise with a friend.
• Use headphones to listen to music or a book on tape.
• Watch TV during exercise.
• Make a game out of it -- play with the children in your life, they are
always moving!
• Walk your neighbor’s dog!
• Get a pedometer.
2. Testing Blood Glucose and Activity
Whether your patient has type 1 or type 2 diabetes, it is important for them to test their
blood glucose when engaging in activity. If your patient has type 2 diabetes, testing
before and after activity allows them to see the glucose lowering effects of activity. For
patients with type 1 diabetes testing prior to activity helps them determine if a snack is
needed before the activity. Blood glucose response to physical activity is affected by the
type, amount, and intensity of the activity; the timing and type of previous meal and
medication; the pre-activity blood glucose level; and the fitness level of the individual.6
High blood glucose levels are a concern prior to activity. In general it is a good idea for
patients with Type 1 diabetes to avoid activity if blood glucose levels are > 250 mg/dl or
if ketones are present since this can result in further rises in both blood glucose levels as
well as ketosis. Patients with Type 2 diabetes should be cautious when glucose levels are
> 300 mg/dl.7 For individualized patient information you should consult their diabetes
provider.
3. Hypoglycemia
Exercise may lower blood glucose levels during the exercise and can last for up to 12-24
hours. If an intense activity, one which lasts for greater than one hour, is performed it is
possible to have hypoglycemic reactions as late as 12 to 24 hours later. This is called
postactivity, late-onset hypoglycemia. Patients taking certain oral diabetes medications
or insulin are at risk for hypoglycemia. To prevent hypoglycemia for both type 1 and
type 2 patients, they should be instructed by their physician to test their blood glucose
before and after activity to monitor their response. They should also either reduce their
insulin/oral diabetes medications or add a snack prior to the activity. How much
medication they reduce or food they add is based on their pre-activity blood glucose
level. For specific instructions that you can provide for your patients, consult a
physician.
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C. Methods Used to Monitor Diabetes Control
1. Tests for Glycemia
a. Blood Glucose tests are done by lab venipuncture or finger stick which
provides a snapshot of what the blood glucose is at that moment.
b. Glycohemoglobin A1c (HbA1c), now referred to simply as the A1c test,
provides a bigger picture of average blood glucose levels over the last 2-3
months. Glucose attaches or glycates to the hemoglobin of the red blood
cell, which has a lifespan of about 120 days. Therefore, the A1c reflects
the previous 3 months of glycemic control. This is typically done at the
provider’s office or lab every 3 months. Results are not recommended to
diagnose diabetes, but are used to assess efficacy of treatment and risk for
long-term complications of diabetes. The table below shows the
correlation between A1c level and mean plasma glucose levels.8
A1c Mean Plasma Glucose
4 65
5 100
6 135
7 170
8 205
9 240
10 275
11 310
12 345
c. Glycated Serum Protein (GSP), e.g. Fructosamine Assay, is a measure
of the glycation of a serum protein with a half-life of 14-20 days and thus
reflects the blood glucose control over the last 1-2 weeks. This is done at
the lab/provider’s office to document short-term changes in glycemia.
Specifically, this may be used to determine the response to new
medication, a change in an insulin regimen, or when the A1c is not
accurate as is often the case in people with hemoglobinopathies.
Since the advent of home blood glucose (BG) meters, urine glucose testing
is no longer considered a reliable method for monitoring glucose. Glucose
in the urine is not detectable unless blood glucose levels have been above
180 mg/dl.
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2. Self Monitoring of Blood Glucose
a. Benefits
• Provides information to make decisions for diabetes self-management.
• Determines and guides treatment for hypoglycemia.
• Provides information on how food, activity, medication, and stress
affect blood glucose (BG) levels.
• Identifies problem areas and patterns to determine possible causes and
adjust treatment or other variables as necessary.
b. Blood Glucose Goals
The American Diabetes Association (ADA) recommendations for BG
goals are based principally on the results of the Diabetes Control and
Complications Trial (DCCT). They recommend that most individuals
with diabetes should attempt to maintain blood glucose levels as close to
normal as possible. Goals should be individualized between patient and
provider.
ADA 2005 Clinical Practice Recommendations for Glycemic Control9
Hemoglobin A1c < 7%*
Preprandial plasma glucose 90-130 mg/dl
Peak postprandial plasma glucose < 180 mg/dl
Key concepts in setting glycemic goals:
• Goals should be individualized.
• Certain populations (children, pregnant women, elderly) require
special considerations.
• Less intensive glycemic goals may be indicated in patients with
severe or frequent hypoglycemia.
• More stringent goals (i.e., a normal A1c < 6%) may further reduce
complications at the cost of increased hypoglycemia (particularly
in those with type 1 diabetes).
• Postprandial glucose levels may be targeted if A1c goals are not
met despite reaching preprandial glucose goals.
*referenced to a non-diabetic range of 4.0 - 6.0% using a DCCT based
assay.
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Note: Blood glucose recommendations are plasma values. If still using a
monitor that gives whole blood results, the goals pre-meal would
be 80-120 mg/dl, 10-15% lower.
c. How to Choose a Blood Glucose Meter
Considerations for selecting a blood glucose meter include the individual’s
abilities, lifestyle, and preference. Most diabetes educators recommend meter
upgrades using the newer technology, which improves ease of use and accuracy.
No more hanging drops, timing, wiping and cleaning. Meter memory with date
and time are now standard features. Many now come with cables and software
that allow users and providers to download results to computers for easy to read
printouts.
1. Questions to Ask Your Patients
• Can they see the display?
• Can they handle the strip?
• Can they provide the adequate blood droplet?
• Can they apply the blood to the strip?
• Can they code the meter?
• Can they do a control test?
• Do they know whom to contact with questions regarding their
meter?
• Is the meter plasma calibrated or are results given in whole
blood values?
• Is the meter approved for alternate site testing?
• Do they know when they should/should not use alternate site
testing?
d. Tips on Blood Glucose Testing
• Wash hands!!!! Substances on the skin can interfere with results. If
alcohol is used, let it dry completely.
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• If obtaining a sample is difficult, try warming and dangling the hand
first then increase the penetration depth of the lancet if needed.
• Alternate site testing is not recommended during periods of rapid BG
change, e.g. after meals, within 2 hours of taking rapid acting insulin,
after exercise, or if hypoglycemia is suspected. Fingertip testing at
these times more accurately reflects current BG levels.
• Quality meters have a customer service 800# listed on the back of the
meter for questions.
• Most insurance companies help cover testing supplies. Maine Public
Law 592 requires all Maine based insurance companies provide some
type of coverage of testing supplies. Medicare Part B currently covers
80% of testing supplies. Medicare requires a detailed prescription
including diagnosis code, frequency of testing, and most recent A1c
result.
• Lancets become dull after each use. A fresh lancet should be used at
least every 24 hours to prevent infection.
• Dispose of lancets in a non-breakable container such as a thick plastic
laundry detergent bottle or coffee can with a secured lid. Label the
container “Do not recycle.” When full be sure to put into the regular
trash, not the recycle bin.
Note: For more on glucose meters see the Diabetes Health Product
Reference Guide in the back of this section.
e. How Often to Test Blood Glucose Levels
The frequency of self monitoring of blood glucose levels is individualized based
on treatment and goals. The more tests done, the more data available to better
assess control.
• Testing can be done 1-8x per day.
• Testing should be done either before a meal or bedtime, 2 hours after a
meal, and sometimes between 2:00 a.m. - 3:00 a.m.
• Testing before meals and also 2 hours after meals allows for
evaluation of both food intake and medication effect.
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• If taking insulin, a good rule of thumb is to test the same number of
times each day as taking insulin shots; e.g. if taking 4 shots per day,
test 4x/day, if taking 2 shots per day, test 2x/day.
• Testing should be done more frequently during treatment changes.
• If testing 1-2x/day or taking a combination insulin it is recommended
the tests be rotated. This means to test at different times on different
days; e.g., Monday test before breakfast and dinner, Tuesday before
lunch and bed, and alternate this pattern every other day. Use this
information to identify patterns in BG levels.
• Test more frequently if having hypoglycemic unawareness.
• Test if suspect hypoglycemia.
• Test every 2-4 hours when ill.
• Test before driving.
• Test before, during, and after exercise as needed.
f. Keeping a Blood Glucose Log
Keeping a record of BG results and comments regarding activity and food intake
can assist with problem solving. Are values lower on days with more activity?
Are they higher on the weekend? Did the patient eat more than their meal plan
allows last night? Recording BG levels in vertical columns for same time of day
can assist the individual and provider in identifying patterns and trends and can
help guide exercise, meal and medication plans.
g. Alternative testing sites
Many meters are now available to provide glucose results taken from the fingertip
as well as other sites on the body such a the palm, forearm, upper arm, thigh and
calf. This allows a break for the fingertips which is a welcome alternative for
many. However, there has been controversy about when these alternative sites
should be used. It has been shown by some researchers that testing after meals
revealed a difference in test results between the forearm and fingertip. Fingertip
testing is the most accurate. If an alternative site is used, be sure to use the clear
cap with the lancet device which comes with the meter. Below are listed the
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times when a patient should avoid alternative site testing and instead use their
fingertip:
• When feeling hypoglycemic
• Two hours after meals
Note: A blood glucose log example is located in the back of this section.
D. Oral Medication Therapy
To best understand the medications used to treat diabetes, it is helpful to review the cause
of hyperglycemia. Is it from an absolute deficiency of insulin as in type 1 diabetes? Or is
it from insulin resistance, excess release of glucose from the liver, and/or a relative
insulin deficiency as in type 2 diabetes?
In type 1 diabetes (formerly referred to as “insulin dependent” or “IDDM”), the body
does not make insulin. Exogenous insulin is required to sustain life. Injection into the
subcutaneous tissue is the only approved route of administration at this time. Research
continues on other forms including pills that can avoid digestion by the stomach and
insulin that can be inhaled.
Insulin regimens are used to mimic what a normal pancreas would do (e.g. provide a
background level of insulin to maintain blood glucose levels and provide additional
insulin at meal times to compensate for the rise in postprandial glucose). Different
insulin combinations are used to duplicate this effect.
Currently, best glycemic control is achieved with: 1) a QID regimen (4 shots per day)
using a daily long acting insulin (basal) and rapid acting insulin at meals; or 2) Insulin
pump therapy (continuous subcutaneous insulin infusion – CSII), this provides
continuous infusion of a rapid acting insulin via a catheter inserted under the skin. A
BID regimen (2 shots per day) consists of combining a short or rapid acting insulin and
an intermediate acting insulin and would be taken before breakfast and dinner.
In type 2 diabetes (formerly referred to as “non-insulin dependent” or “NIDDM”),
medication is added when medical nutrition therapy (meal planning) and exercise fail to
achieve glycemic control or when the pancreas no longer is able to supply the insulin
needed to control BG levels. Treatment is aimed at the underlying reasons for
hyperglycemia: insulin resistance, excess hepatic glucose and insulin deficiency.
There are five classes of oral medications. Each class works in different ways to control
blood glucose and are typically used in combination with each other or insulin. While
many augment the insulin supply like the Sulfonylureas and the Meglitinides (i.e.
stimulate the pancreas to secrete more insulin), several enhance the effectiveness of
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endogenous insulin (i.e. allow one’s own insulin to work better) as do the Biguanides,
Thiazolidinediones, and Alpha-glucosidase Inhibitors.
The Biguanides (metformin) inhibit the liver from releasing too much glucose and also
help to sensitize the muscle cells to insulin. The Thiazolidinediones (TZD’s) (Actos &
Avandia), make fat cells and muscle cells more sensitive to insulin. Alpha-glucosidase
Inhibitor’s (Precose & Glyset) main site of action is the intestine; they slow the
digestion of some carbohydrates. The Meglitinides (Prandin & Starlix) stimulate the
pancreas to secrete more insulin but only in response to a rise in glucose levels.
Generally speaking, Alpha-glucosidase Inhibitors reduce the A1c 0.5-1% while all
others typically lower it 1-2%.10 When agents are combined, their efficacy is generally
additive. Currently there are 3 oral medications that combine the above: Glucovance,
Metaglip, and Avandamet.
Insulin therapy can be used alone or in combination with oral agents to help patients
achieve and/or improve target glucose control. If contraindications exist, or
combinations of oral agents fail to achieve glycemic goals, the addition of insulin is
indicated. If an individual with type 2 diabetes requires insulin for control, they still have
type 2 diabetes; they do not suddenly become type 1. This is often mistaken. Key
teaching points for patients on oral medications should include how they work, when they
should be taken in relation to food, possible side effects, contraindications, and
particularly precautions and treatment for hypoglycemia.
Note: Oral medication options are limited for patients with hepatic or renal dysfunction,
CHF, advanced age, and pregnancy.
Note: A list of oral medications is available in the Diabetes Health Product Reference
Guide located in the back of this section.
E. Insulin Basics
Insulins have different properties; type, concentration, purity, and source that determine
their time-activity profiles (in other words how they work).
Note: Time Activity Profiles are in the back of this section.
1. Type refers to the onset, peak, and duration of its action. Each type is
considered to be either rapid-acting, short-acting, intermediate-acting or longacting.
Usually an intermediate or long-acting insulin is used in conjunction
with short or rapid acting insulin. Pre-mixed insulins are also available.
These are insulin preparations with a predetermined proportion of insulins,
e.g. 70% intermediate acting with 30% short acting insulin.
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2. Concentration refers to the strength of insulin. All of the insulin used in the
United States is U-100 concentration; 100 units per milliliter. U-500 insulin is
available by special order only.
3. Purity of insulin is expressed as parts per million of proinsulin, the primary
contaminant after extraction from animal pancreas or dissolution of cells used
for recombinant DNA reproduction of insulin molecules. Purity of insulin is
almost a non-issue today as all insulins are highly purified.
4. Sources of insulin before 1983 were from beef and pork pancreas. Human
insulin is now the most prescribed. Beef sources were discontinued in 1994.
Human insulin is produced synthetically by recombinant DNA technology
(biosynthetic) or by a chemical conversion of pork insulin to human insulin
(semi-synthetic). Insulin analogs (Humalog and Novolog) have been
developed through the modification of the amino acid sequence of the insulin
molecule.
Side Effects to insulin include local and general allergy, hypoglycemia, weight gain,
decreased serum potassium, and changes in fat tissue at the injection site. Insulin is
administered by syringe, insulin pen or insulin pump. Insulin pens may be carried in a
purse or shirt pocket and therefore make it easier for patients to adhere to their insulin
regimen.
F. Insulin Pumps
Insulin pumps provide a continuous delivery of rapid acting insulin. Insulin pumps allow
owners to have greater flexibility in managing their diabetes. The major advantages of an
insulin pump are improved insulin absorption; the ability to change the amount of insulin
delivered at any time throughout the day due to changes in exercise, food intake, stress,
illness, hormonal changes, and certain medications; as well as less daily injections.
Disadvantages that need to be considered are: being connected to a medical device all
the time, the protection of long acting insulin is not available (therefore if a pump fails to
work, DKA can have a rapid onset), and there may be an increase in the cost of supplies
for a pump versus traditional syringes.
Pump wearers (also frequently referred to as “pumpers”) learn how to program their
pump to deliver a basal rate (for background needs) and a bolus (to cover food). They
may give extra insulin when blood glucose levels are high or they would like to enjoy an
extra snack or dessert. They are also able to program a temporary basal rate to reduce
their insulin during exercise or increase it as is often necessary during illness.
Education provided to pumpers is extensive. Since an insulin pump is merely another
method used to deliver insulin, pumpers still need to know the basics of how to treat
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hypoglycemia, illness, and hyperglycemia. They need to be testing their blood glucose
levels at a minimum of four times per day, testing for ketones when appropriate; and
counting the carbohydrates in the foods they eat. In addition to these basics, pumpers
need to know how to identify problems with their pump, pump site, and insulin; as well
as how and when to set the pump aside and correct problems using a syringe and insulin.
Diabetic Ketoacidosis has a rapid onset so being able to identify and attend to these
problems immediately is crucial.
A good insulin regimen is one that achieves targeted glucose goals, minimizes
hypoglycemia, and is acceptable to the patient.
Note: It is important to remember that individuals respond differently to insulin doses.
Disposal of syringes and needles:
Dispose of syringes in a non-breakable container such as a thick plastic laundry detergent
bottle or coffee can with a secure lid. Label the container “Do Not Recycle.” When full,
be sure to put into the regular trash, not the recycle bin.
.
G. Insulin Guidelines and Pens
Note: Guidelines for the Use of Insulin and Special Guidelines for Insulin Pen Use are
located in the back of this section.
H. Incretin Mimetics
Byetta (exenatide) is an injectable diabetes medication for type 2 diabetes. It is the first
medication in a new class called Incretin Mimetics. Byetta is currently indicated for use
with patients who have not yet achieved adequate blood glucose control taking
metformin, a sulfonylurea (glyburide, glynase, glipizide) or both.
Byetta “mimics” the glucose lowering effects of the human incretin hormone known as
glucagon-like peptide-1 (GLP-1). This is secreted in response to food intake. GLP-1 has
many effects on the stomach, liver, pancreas, and brain that work together to regulate
blood glucose. These effects include:
• Stimulating the body’s ability to produce insulin in response to a rise in blood
glucose level.
• Preventing the release of the hormone glucagon following meals.
• Slowing the rate of nutrient absorption.
• Reducing food intake.
The most common reported side effect of Byetta is nausea, or a sense of fullness. This
typically occurred in the first few weeks of therapy and then improved. In fewer cases
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vomiting, diarrhea, jitteriness, dizziness, and headache occurred. Byetta used alone does
not cause hypoglycemia. However, it may cause other diabetes medications to work
better. Caution patients to be prepared to treat hypoglycemia.
Note: Guidelines for the Use of Byetta and Special Guidelines for Byetta Pen use are
located in the back of this section.11
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Blood Glucose Log
Name________________________
Date
Before
Bkfast
After
Bkfast
Before
Lunch
After
Lunch
Before
Supper
After
Supper
Before
Bed
Comments
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Guidelines for the Use of Insulin
Patient Instructions
Timing of Insulin Dose:
Each insulin starts working and peaks at different times. It is important that you use the
following guidelines for the timing of your insulin:
• Never skip an injection (even if you are sick and cannot eat) without
consulting with your diabetes team first.
• For Regular (R) insulin, take your shot one half hour before your meal.
• For Humalog (H) insulin or Novolog, take your shot within 15 minutes of
your meal (usually just before eating).
• For Long Acting (NPH, Lente) or Basal (Lantus) insulin take your shot at a
consistent time of day.
Drawing Up and Mixing Insulins:
• Do not use insulin if you notice clumps in it, or if there are color changes.
• Always wipe the tops of your insulin vials or pens with alcohol before using.
• Roll vials of NPH, 70/30 or 75/25(cloudy insulin) before drawing up the
insulin dose.
• Turn back and forth the pens of NPH, 70/30 or 75/25(cloudy insulin) before
dialing or counting the insulin dose.
• When mixing two types of insulin in the same syringe, always make sure to
draw up the short-acting (Regular or Humalog) first.
• Lantus insulin CANNOT be mixed in the same syringe with any other insulin.
Injecting Insulin:
It is important that the insulin be injected into the fat layer and not the muscle. For this
reason we recommend:
• Clean site
• Pinch up the skin
• Hold the syringe like a dart and push straight into the skin
• Inject the insulin
• Release the pinch after 3-5 seconds
• Pull out the syringe
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Injection Site Options:
• Stomach (avoid 2 inches around belly button) – absorbs
at faster speed.
• Outside of upper arms – absorbs at medium speed.
• Top and outer side of thighs – absorbs at slower speed.
• Upper part of buttocks – absorbs at very slow speed.
Note: We recommend stomach and thighs, unless somebody else is giving
you the injection.
It is recommended that you use the same site for injection at the same
time of day (for instance use your thighs in the morning and your
stomach in the evening). You should rotate where you inject within that
site so you aren’t going in the same spot over and over again. Avoid
areas of fat buildup, hardening or scarring. Notify your health care
provider if you note any changes at injection sites.
Syringe Reuse and Disposal:
• Many people safely reuse their syringes for up to 24 hours.
• If you choose to reuse your syringe, you cannot use the same syringe for
Lantus that you’ve used for other insulins. If someone else fills the syringes
for you, do not reuse these to prevent needle stick injuries.
• Once you are done with your syringe put it in a heavy plastic container such
as a laundry detergent bottle. When it is near full, tape the cover closed and
label it “do not recycle.”
• Contact your local city or town to ask if it is safe to put the full container in
the trash.
Storage of Insulin:
• It is the manufacturer’s recommendation that you store insulin in the
refrigerator.
• Short acting insulin pens (Humalog and Regular), and any vial of insulin
(short and long acting), are good for one month.
• Longer acting insulin pens are good at room temperature fewer days: 14 days
for NPH insulin pens and 10 days for 70/30 or 75/25 insulin pens.
• If you store insulin at room temperature make sure it is not stored in direct
sunlight, in a bathroom that may get hot and humid, above a stove, in a car
when it’s hot or cold, or anyplace there may be extremes in temperatures.
• Once a vial of insulin has been opened, it should be discarded after one month
regardless of where it has been stored.
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Special Guidelines for Insulin Pen Use
• If your pen has long acting insulin (NPH, 70/30 or 75/25) you must mix the
insulin first by inverting the pen (turn up and down) 15-20 times.
• You need to push air out of the needle before every injection. To do this “air
shot” dial 2 units and inject the insulin into the air. Then you can dial the dose of
insulin you need to give yourself.
• After injecting the insulin you must slowly count to 5 before taking the needle out
of your skin.
• Be sure the dose knob is fully depressed each time to ensure you receive the full
dose. For Novolog Pen and Innolet doser, check that the dose dial reads “0”; for
Lilly pen, check that the dose knob rotates freely.
• Always remove the needle from the pen after you’ve injected the insulin so
bacteria and air cannot get into the insulin. Do not carry the pen around with a
needle on it for this same reason.
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Guidelines for the Use of Byetta
Patient Instructions
When starting Byetta, you need to remember that no medication by itself will control
your diabetes. All medications, including Byetta, will work best when combined with
increased activity and a sensible meal plan.
Timing of Byetta Dose:
• The starting dose is 5 mcg per injection, this will increase to 10 mcg after the
first month.
• Inject 60 minutes before breakfast and dinner.
• If you forget to take your dose and have already eaten, skip that dose and get
back on track for the next one.
• Should you need to take antibiotics, oral contraceptives, or thyroid medication
they need to be given one hour prior to Byetta or at a different time of day
such as noon or bedtime.
Dialing Dose :
• The first time you use each pen you need to dial a dose and waste it – this
primes the pen. Each following injection you only need to apply a new needle
and inject.
• Do not use the medication if you notice clumps in it, or if there are color
changes.
• Always wipe the tops of the pen with alcohol before applying the pen needle.
• See back of this page for specific dialing dose instructions.
Injecting Byetta:
It is important that Byetta be injected into the fat layer and not the muscle. For this
reason we recommend:
• Clean site
• Pinch up the skin
• Hold the syringe like a dart and push straight into the skin
• Inject the insulin
• Release the pinch after 3-5 seconds
• Pull out the syringe
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Injection Site Options:
• Stomach (avoid 2 inches around belly button)
• Outside of upper arms
• Top and outer side of thighs
• Upper part of buttocks
Note: We recommend stomach and thighs (unless somebody else is
giving you the injection).
You should rotate where you inject within that site so you aren’t going
in the same spot over and over again. Avoid areas of fat buildup,
hardening or scarring. Notify your health care provider if you notice any
changes at injection sites.
Pen Needle Reuse and Disposal:
• It is not recommended you reuse pen needles.
• Do not leave needles attached to the pen, remove and discard properly after
each use.
• Once you are done with your needle put it in a heavy plastic container such as
a laundry detergent bottle. When it is near full, tape the cover closed and
label it “do not recycle.”
• Contact your local city or town to ask if it is safe to put the full container in
the trash.
Storage of Byetta:
• It is the manufacturer’s recommendation that you store Byetta in the
refrigerator at all times.
• When traveling keep Byetta cool by wrapping it in a small piece of cloth and
placing in a cooler or use a small carrying case with a small cold pack. Avoid
placing directly against ice or cool packs. Do not use if it freezes. Protect the
pen from sunlight. Each pen should be discarded after 30 days.
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Special Guidelines for Byetta Pen Use
• You need to push air out of the needle before the first injection when you open a
new pen. To do this “air shot” dial one full dose (either 5 mcg or 10 mcg) and
inject the medication into the air/sink. Then you can dial the dose of Byetta you
need to give yourself. Each following injection you can simply apply the needle,
dial the dose and inject.
• After injection Byetta, you must slowly count to 5 before taking the needle out of
your skin.
• Always remove the needle from the pen after you’ve injected Byetta so bacteria
cannot get into the medication. Do not carry the pen around with a needle on it
for this same reason.
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V. ACUTE COMPLICATIONS
A. Hypoglycemia (Low Blood Glucose)
Hypoglycemia occurs when blood glucose levels fall below 70 mg/dl. When this
happens, most people have unpleasant symptoms. These symptoms usually come on very
suddenly. Hypoglycemia is easy to treat and easy to avoid!
1. Symptoms
There are early, moderate and late/severe stages of symptoms. Instruct your patients to
monitor their blood glucose level and treat at the first sign of any symptoms.
2. Causes
• Taking more diabetes oral medication or insulin than needed
• Skipping meals or not eating enough (especially carbohydrates)
• More activity than usual
• Taking medication at the wrong time
• Drinking alcohol
According to the ADA, daily alcohol intake should be limited to 1 drink for
women and 2 for men. One serving is equal to 12 ounces of beer, 5 ounces of
wine or 1.5 ounces of distilled spirits.12 Light to moderate amounts decrease the
risk of heart disease. The danger of drinking alcohol can be low blood glucose
levels for any person taking insulin or oral diabetes medication and can happen
12-16 hrs after significant alcohol intake.
EARLY MODERATE LATE/SEVERE
Shaky Slurred speech Seizures
Sweaty Confusion Unconsciousness
Weak Lethargy
Hungry
Dizzy or lightheaded
Headache
Palpitations
Blurred vision
Some people have
no symptoms at all
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Alcohol consumption should be discussed with the provider. If approved, the
following guidelines are offered for many patients:
• No more than 1 drink for women and 2 drinks for men no more than 2
times per week with food.
• Do not drink alcohol on an empty stomach.
• Limit or avoid altogether drinks that contain large amounts of sugar such
as liquors, sweet wines and sweet mixers.
• Avoid alcohol if diabetes is in poor control. Wait until blood glucose
levels are in better control.
• Avoid alcohol if triglycerides are elevated since alcohol tends to raise
them.
3. Treatment
Hypoglycemia needs to be treated immediately. It is recommended that people taking
oral diabetes medication or insulin keep carbohydrate sources on hand at all times in case
of a hypoglycemic reaction. Some people feel the symptoms of hypoglycemia when their
blood glucose is < 80 mg/dl. However, most do not feel symptoms until < 70mg/dl. Any
patient should use the “Rule of 15” to treat hypoglycemia when blood glucose levels fall
below 70 mg/dl.
Rule of 15
a. Test your blood glucose if feeling symptomatic
b. If < 70 mg/dl, take 15 grams of carbohydrate
Examples of 15 grams of carbohydrate:
• 4 oz. juice
• 3-4 glucose tablets
• 2 tbsp. raisins
• 4-5 oz. regular soda
• 10 oz. skim or lowfat milk
c. Wait 15 minutes
d. Retest your blood glucose
e. If < 70 mg/dl, then treat again with 15 grams of carbohydrate;
continue treating until BG > 70 mg/dl.
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Never force food or drink into the mouth of someone who may be having a
hypoglycemic reaction; this could cause choking. Instead, try to offer a drink of
juice, milk, or regular soda. Often people will follow directions to drink or eat
even when they are unable to verbalize this need.
For unconsciousness suspected to be hypoglycemia, give glucagon, a hormone
that causes stored glucose in the liver to be released into the bloodstream. It is
available by prescription only and does have an expiration date. This needs to be
reconstituted before injecting SC or IM. Patients with type 1 diabetes should be
encouraged to keep a glucagon injection kit at home at all times and when
traveling.
4. Prevention
• Avoid skipping meals or snacks
• Monitor blood glucose levels on a regular basis
• Teach patients to adjust their food and insulin when increasing or decreasing
their activity level
5. Medic-Alert Identification
It is recommended that any person taking oral diabetes medication and/or insulin
wear medic-alert identification. In an emergency it may help others to identify
why a person is acting as they are, such as confused. It can also help emergency
personnel care better for a person in an accident or some other event when they
are unable to speak for themselves.
B. Hyperglycemia (High Blood Glucose)
Normally, for someone without diabetes, fasting blood glucose levels are maintained
between 60-115 mg/dl. For diagnostic purposes, hyperglycemia occurs when fasting
blood glucose levels rise above 125 mg/dl. Remember that pre-diabetes exists when
fasting blood glucose levels are between 100-125 mg/dl. Blood glucose levels change
constantly depending on many factors.
1. Symptoms
• Increased hunger
• Increased thirst
• Increased urination
• Fatigue
• Blurred vision
• Frequent infections
• Slow healing of cuts or sores
• Weight loss
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Note: In many individuals glucose levels rise at such a slow rate they adjust to
the increasing levels without noticing.
2. Causes
• Eating more food than meal plan allows
• Emotional stress
• Illness/pain/surgery/infection
• Not taking enough diabetes medication or taking it at the wrong time
• Certain medications (i.e., prednisone)
3. Treatment
Regardless if a patient has diabetes or pre-diabetes, the recommended lifestyle
changes are the same:
• Meal planning – decreasing portion sizes, limiting high fat foods, drinking
mostly calorie-free beverages.
• Exercise – any kind of activity beyond what a person is currently doing
will help to lower blood glucose levels.
• Weight loss – even a modest weight loss helps the cells of the body to use
glucose better.
• Monitoring blood glucose levels – knowing current blood glucose levels
helps people make decisions about self care (need to take a walk, need to
eat less/more, need to manage stress better, etc.).
As previously discussed, there are several types of oral medications and insulins
to help control blood glucose levels.
4. Prevention
• Follow the meal plan.
• Increase activity.
• See the doctor for any cuts/sores that do not heal quickly.
• Take medications at the right times.
C. Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis is a serious complication of diabetes. It is caused by a lack of
insulin or an elevation in stress hormones which increases insulin resistance. When
insulin levels are low, glucose stays in the bloodstream. The body looks for an alternate
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energy source and breaks down fat for fuel. The by-product of this process are acids
called ketones.
Some people are more prone to developing ketones than others. Ketoacidosis is more
common for people with type 1 diabetes, however people with type 2 have also
developed this. Ketoacidosis may occur with illness, or during periods of increased
stress, or with poor insulin adherence.
1. Symptoms
• Nausea or vomiting
• Abdominal pain
• Increased thirst/dehydration
• Chest pain
• Fruity smelling breath
• Clouding sensorium
• Shortness of breath
2. Causes
• Lack of insulin
• Elevation of stress hormones
3. Treatment
Ketoacidosis is a serious complication of hyperglycemia and needs to be treated
immediately clearing the body of ketones requires:
a. Blood glucose testing – at least every 4 hours while sick.
b. Urine ketone testing – this is done by holding a ketone test strip in the
urine stream; after 15 seconds the color is compared to the color code
on the bottle – the deeper purple color means the more ketones a
person has.
• Test for ketones with every urine while sick as well as anytime
blood glucose is > 240 mg/dl twice in a row.
c. Increasing fluids ½-1 c per hour; switch to salty fluids if vomiting or
diarrhea occur, or if ketones are present. Fluids are critical in
preventing dehydration.
d. Extra short acting insulin is given with physician guidance generally
every 2-3 hours while the blood glucose is high and there is presence
of moderate to large ketones.
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e. Possible hospitalization for IV hydration and correction of electrolyte
imbalances.
Note: Ketostix may be purchased in a vial, expiring in 6 months, or foil
wrapped, expiring as dated (this may be as long as 1 – 2 years or longer).
4. Prevention
• Take all medications/insulin as prescribed.
• Treat any and all illnesses in a timely manner.
• Test for ketones when blood glucose is ≥ 240 mg/dl twice in a row and/or
when ill.
• Flu shot.
• Pneumovax.
Note: There are dual function meters that test both blood glucose and ketone
levels.
D. Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS)
Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS) is a serious problem that
occurs in people with type 2 diabetes.
1. Symptoms
• Higher than normal blood glucose levels (e.g., 600’s)
• Excessive thirst
• Increased urination
• Hunger
• Nausea or vomiting
• Rapid shallow breathing
2. Causes
Causes are high blood glucose levels that eventually cause dehydration and
electrolyte imbalances. This is most common in elderly patients. It usually
develops over a period of days as a result of high blood glucose levels, illness,
and/or dehydration.
3. Treatment
• Treat the illness that is causing the high blood glucose levels.
• If antibiotics are prescribed, take all pills as directed.
• Alert the doctor caring for the person that they have diabetes.
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• Prevent or treat dehydration!
• Drink ½ to 1 cup of fluid every 30-60 min; if unable to drink much, switch
to salty fluids such as bouillon, broth or soup.
• Hospitalization may be required for IV hydration and correction of
electrolyte imbalances.
4. Prevention
Instruct patients to do the following:
• Follow sick day guidelines for adequate hydration, self monitoring of
blood glucose levels and when to call the doctor.
• Take all medications as prescribed – never skip them.
• Monitor blood glucose levels more often.
• Test urine for ketones if blood sugar is > 300 mg/dl.
• Flu shot.
• Pneumovax.
E. Sick Day Guidelines
High blood glucose levels due to illness can turn a minor illness into a major
problem. When the body is under stress from illness or pain, it releases hormones
to help fight disease or make repairs as necessary. These hormones cause blood
glucose levels to rise and interfere with the blood glucose lowering effects of oral
medications and insulin. Higher blood glucose levels during an illness left
untreated can lead to Diabetic Ketoacidosis or Hyperosmolar Hyperglycemic
Non-Ketotic Syndrome. Both conditions are dangerous and can be lifethreatening.
1. What Patients Should Do When Ill:
• Test blood glucose at least every 4 hours.
• If type 1 diabetes, test urine for ketones with every void.
• Increase fluids → ½-1 c of fluid per hour – change to salty fluids for
vomiting or diarrhea (bouillon, broth, soup, etc.).
• If unable to eat usual foods, switch to sick day food list.*
• Give extra short acting insulin as directed by the provider
• Instruct patients to call their doctor if:
o Moderate to large ketones appear after testing.
o Vomiting occurs more than twice or continues for > 6 hours.
o Unable to keep fluids down.
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o Blood glucose levels are > 240 mg/dl despite taking extra insulin.
o Blood glucose is > 240 mg/dl for more than 24 hours for patients
with type 2 diabetes.
o They do not know how to care for themselves.
2. Prevention
• Yearly flu shot
• Pneumonia shot
*Note: The sick day food list is in the back of this section.
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Sick Day Foods
If you are unable to eat your usual foods, replace each 15 grams of carbohydrate in your
usual meal with any of the fluids or soft foods listed below. Each of the foods in the
amount listed below have 15 grams of carbohydrate.
Foods/Beverages Amount
Custard, regular 1/2 cup
Fruit juices (except grape) 1/2 cup
Grape juice 1/3 cup
Honey 3 teaspoons
Ice cream 1/2 cup
Jell-o (regular) 1/3 cup
Milk 1 and 1/4 cups (10 ounces)
Milk shakes 1/4 cup
Popsicle (regular) 1 whole
Saltine crackers 6 each
Sherbet 1/4 cup
Soda pop (containing sugar) 3/4 cup
Soups (broth based, reconstituted with
water or cream)
1 cup
Sports drinks (Gatorade) 1 cup
Toast 1 slice
Yogurt (with Aspartame/Nutrasweet) 1 cup
Yogurt (regular) 3 ounces
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VI. STRESS AND DIABETES
As we all know, stress can occur at any time. Both the environment and people influence
stress. Positive and negative situations can be stressful. It is important to be aware of the
impact that stress has on people with diabetes because stress raises blood glucose levels.
This occurs for two reasons: (1) the hormones released when a person is under stress
may cause blood glucose levels to rise, and (2) a person may not care for themselves or
their diabetes when under stress. For example: they may revert to smoking, discontinue
their medications, stray from their meal plan, or stop testing their blood glucose levels.
A. Sources of Stress
• An illness or infection (even a cold)
• Intense emotions – fear, sadness or anger
• Worry
• Pain
B. Getting a Handle on Stress
Recognizing stress as an ongoing part of life may be the first step to dealing with it.
Encourage patients to try one of the following:
1. Work Off Stress
If you are angry or upset, try to blow off steam physically by engaging in an
activity that you enjoy, such as tennis, running or gardening. Even a walk can
help.
2. Talk Out Your Worries
It helps to share worries with someone that you trust and respect. Sometimes
another person can help you see another side of the problem and thus, a new
solution.
3. Learn to Accept What You Cannot Change
If the problem is beyond your control at the time, try your best to accept it until
you can change it. It beats spinning your wheels and going nowhere. Ask
yourself, “Can I do anything to change this?” If the answer is no, move onto
something else you can feel in charge of.
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4. Get Enough Sleep and Rest
Lack of sleep can lessen your ability to cope with stress.
5. Balance Work and Recreation
“All work and no play can make Jack a nervous wreck!” Schedule time for fun to
relax your mind. Although inactivity can cause boredom, a little loafing now and
then can ease stress.
6. Do Something for Others
Doing for others can make you feel better and can help you to see what others are
dealing with. It may help to put your worries into a different perspective.
Contributing to an individual person or group can help you see that you did
indeed make a difference for someone else today!
7. Take One Thing at a Time
It’s helpful for many of us to make a list detailing what we need to accomplish.
However, this can also feel overwhelming and defeating if the list is too big, so
start small. Break your list down to “today” and “later” to help you focus on the
most urgent issues.
8. Learn to Compromise
If your stress is other people, try giving in once in a while – maybe soon they will
too.
C. Depression and Diabetes
When coping skills fail, it is important to be aware that people with diabetes are more at
risk for developing depression. Signs and symptoms of depression are: depressed mood;
loss of interest in things usually enjoyed; feeling down, depressed or hopeless; sleeping
too much or too little; poor appetite or overeating; decreased energy level; and
decreased ability to concentrate or make decisions. 13
The American Diabetes Association recommends incorporating psychological assessment
and treatment into routine care. While there are many tools available to assess
depression, the Patient Health Questionnaire (PHQ9) is being used by many MaineHealth
facilities.
Note: The Patient Health Questionnaire (PHQ9) to use when assessing your patient for
depression is in the back of this section.
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D. Diabetes and the Family
Family members are also affected by diabetes. Everyone in the family has feelings about
it. How the person with diabetes feels can reflect on how family members feel and how
they interact with each other. This in turn can influence how well blood glucose levels
are controlled.
Family members may feel angry because of the time required to take care of diabetes; or
they may feel worried that the diabetes is not being taken care of as it should be. They
also may be fearful of the potential for complications. It is important to include them in
the educational process.
Help patients to recognize how others in their family can help them take care of their
diabetes. While no one else can really take care of the patient’s diabetes except
themselves, family members can play a supportive role by:
• Eating healthy meals together
• Exercising together
• Planning and cooking healthy meals
• Going to healthcare visits together
• Attending educational programs together
• Sharing feelings/concerns
• Listening
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VII. THE CHANGE PROCESS
Consider where a patient may be in the change process when developing a plan of care.
If they are not quite ready for action, allowing them to verbalize their feelings about their
diagnosis by providing support and encouraging them to try one or two small changes at
each visit can help move them toward modifying their behavior long term. The following
are the steps they will experience during the change process:
• Pre-Contemplation – Not considering making any change.
• Contemplation – Thinking about making a change in the foreseeable
future.
• Preparation – Seriously considering making a change in the near future.
• Action – Making the change.
• Maintenance – Incorporating new behavior into a routine over an extended
period.14
Staying healthy with diabetes usually means making some changes. However, changing
habits is difficult and often feels uncomfortable. Setting goals for behavior change can
help a person make the change. It takes time to make ones that will last and set backs
may occur. Below are a few suggestions you can use with your patients when discussing
behavior change:
• Have them start with something they are willing to do.
• Encourage them to choose what they want to change, make a plan for the
change and then do the change.
• Identify a goal that is reasonable and measurable.
• Identify costs and benefits of the behavior change.
• Determine a reward (not food) when a short-term goal is accomplished.
• Write a contract if necessary between the patient and support team (RN,
LPN, MD, family, friends, diabetes educator, etc.).
• Be prepared for set backs – how will the patient deal with them? – can
they change their original goal to help them stick to it better?
A. Goal Setting Example
Susan was recently diagnosed with diabetes. She is 55 years old, married, the mother of
four children and works full time. Although it was difficult for her to find time, she
attended Diabetes Self-Management Education (DSME) classes at her local hospital. At
the end of the program, she was asked to make one behavioral goal for herself. She
decided to get up one hour earlier Monday through Friday and walk on her treadmill for
one hour.
Susan did well at first. She lost seven pounds and her blood pressure decreased from
145/94 to 138/85. Six weeks into her program, her mother became ill and her oldest
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daughter had twins. She found herself unable to continue her program and instead
invested her time into caring for her family. “After all,” she told herself, “it’s just for a
little while.” Before she knew it, two months had gone by. She had gained five pounds,
felt very fatigued, and didn’t remember the last time she checked her blood pressure. In
addition, she realized she had not been paying very close attention to her meal plan.
Susan restarted her exercise program, checked her blood pressure and pulled out her meal
plan to plan her meals for the week. She began walking on the treadmill 3 days per week
for 60 minutes, and walking with her daughter and grandsons the other two days. Within
3 weeks she was feeling better and had lost two pounds.
What helped Susan achieve her goal?
1. Being very specific about the activity (walking).
2. Being very specific about when she would walk and for how long (Mon-
Wed-Fri for 60 min).
3. Revising her plan when she found it was not working.
B. Behavior Change Goals
Patients can work with their diabetes care team to choose the most helpful ways to reach
their health goals. Behavior change goals need to be specific and measurable. If goals
are too big or vague, people may become overwhelmed by what they need to do. Also,
they may not know where to start or if they ever achieve success.
1. Long-Term Goals
A long-term goal is something a person wants to work toward and achieve at
some point in the future.
Examples of Long-Term Goals:
• Improve my A1c (or blood glucose)
• Improve my nutrition
• Improve my physical fitness
• Reach or maintain a healthy weight
• Reduce stress
• Reduce my chance for complications (problems from diabetes)
• Improve my blood pressure
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• Improve my lipids (blood fats)
• Lower my chance for heart disease
• Improve my foot care
• Get my needed tests/exams/immunizations
2. Short-Term Goals
Short-term goals are small changes made over a short period of time.
Examples of Short-Term Goals:
• I will walk for 20 minutes three days each week (Saturday,
Monday, and Wednesday) in my neighborhood.
• I will go to the mall Friday and find out when they are open for
walking.
• I will drink diet soda instead of regular soda for the next week.
• I will eat breakfast every day before I go to work.
• I will keep cut-up carrots in my refrigerator to eat for a snack.
• I will check my blood sugar on Tuesday and Saturday before
breakfast and two hours after dinner.
• I will write down all of my blood sugar results for two weeks and
bring them to my next doctor’s appointment.
• I will check my feet for cuts and sores every day when I get
dressed in the morning.
• I will use the deep breathing relaxation technique I learned today
whenever I feel tense during the next week.
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3. Acceptable Goals
Take a look at the following goals and see how they were adjusted to make them
more specific, measurable and attainable:
Unacceptable Goal:
I will lose 20 pounds.
Acceptable Goal:
I will eliminate chips as a snack; instead will try carrots
with a lowfat dip.
Unacceptable Goal:
I will lower my blood pressure.
Acceptable Goal:
I will not add salt to food and will decrease bacon & ham to
once per week.
Unacceptable Goal:
I will become more active.
Acceptable Goal:
I will walk 45 minutes at the gym Mondays, Wednesdays,
& Fridays.
Unacceptable Goal:
I will avoid hypoglycemia.
Acceptable Goal:
I will take my oral medication with meals; or
I will test my blood glucose if I have symptoms; or
I will carry carbohydrates with me at all times.
Note: Diabetes Self-Care Action Plan is located in the back of this section.
C. Diabetes Educators
A Certified Diabetes Educator (CDE) is frequently a registered nurse or a registered
dietitian, although there are other disciplines who may become certified. To become
certified, a clinician needs to complete two years and 1000 hours of direct patient
education as well as pass a national certification exam. A CDE helps people with
diabetes learn more about the disease and how to live a long, productive life with it.
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Diabetes Educators provide:
1. Comprehensive education.
2. Support.
3. Instruction for glucose meters, insulin pens, insulins & oral medications,
meal plans, and insulin pump therapy, to name a few.
In addition, educators are an invaluable resource to physicians and their office staff. To
locate an educator near you, call the Diabetes Prevention and Control Program at
(207) 287-5180 or go to http:www.maine.gov.
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VIII. DIABETES AND PREGNANCY
Planning ahead is very important for people with diabetes when considering having a
baby. High blood glucose levels can be harmful to both a mother and her unborn baby.
Even before becoming pregnant, blood glucose levels should be as close to the normal
range as possible. Keeping blood glucose levels near normal before and during
pregnancy helps protect both mother and baby; preventing miscarriages and birth defects.
Insulin needs will change during pregnancy. The Obstetrician or Diabetes Specialist may
increase insulin dosages and instruct patients to check their blood glucose levels more
often. If taking diabetes pills, the provider will switch the patient to insulin.
Patients planning to become pregnant should be encouraged to:
• Work with their health care team to get blood glucose levels as close to the
normal range as possible.
• See a provider who has experience in taking care of pregnant women with
diabetes.
• Have their eyes and kidneys checked. Pregnancy can make eye and kidney
problems worse.
• Don’t smoke, drink alcohol, or use harmful drugs.
• Follow the meal plan prescribed by the dietitian or diabetes educator to ensure
a healthy diet.
A. Preconception Visit
Any health care visit by a woman, who has diabetes and is in her childbearing years,
should be considered a preconception visit. At these visits, birth control needs should be
discussed along with any plans for pregnancy.
At each visit the provider will:
1. Take a health history and do a physical exam.
2. Take blood tests including a Hemoglobin A1c.
15
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VIII-2
3. Order special exams needed before becoming pregnant:
a. Kidney function test – urine screen for microalbumin*
b. Eye exam to check retina*
c. Blood pressure
d. Electrocardiogram
*Note: If kidney, heart or eye disease exists, especially if
untreated, a woman may be a risk for further
damage/complications if she becomes pregnant.
4. Look for and treat any problems (especially infertility problems).
5. Ask at every visit if she is planning to become pregnant.
6. Ask if the woman and her partner are ready to become parents; are income
and finances an issue? Being both pregnant and having diabetes can cause
emotional and financial stress.
7. Talk with the prospective parents about good blood glucose control before
planning to become pregnant. There is an increased risk of malformations
of the baby during the early weeks of conception with poor glucose
control. Therefore, it is important to obtain good blood glucose control
prior to becoming pregnant.
8. Assess the woman’s diabetes control at home. The provider may ask:
a. How do you treat low blood glucose reactions? Do you know what
to do in case of a reaction? Do you or someone else in the family
know how to use glucagon?
b. Are you willing to do your blood glucose monitoring more often,
four or more times per day?
c. If on an oral medication for diabetes, are you willing to give
yourself insulin?
d. Are you willing to use birth control until targets for diabetes
control are achieved (Hemoglobin A1c < 7%)?
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9. Take blood tests to check resistance to Rubella.
10. Encourage healthy habits such as getting enough rest and eating plenty of
fruits and vegetables; as well as discourage unhealthy habits such as
smoking and drinking alcohol. Seeing a dietitian will be encouraged, as
will exercise!
.
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IX. TESTING AND COMPETENCIES
A. Diabetes Study Guide Pretest/Post test
1. What affect does exercise usually have on blood glucose?
a. Decreases blood glucose
b. Increases blood glucose
c. Has little effect on blood glucose
d. I do not know
2. Why is it necessary that individuals with diabetes take special care of their feet?
a. A number of years of injecting insulin into the thighs can cause edema in
both the legs and the feet.
b. Flat feet are commonly associated with diabetes unless preventive
measures are used routinely.
c. Persons with diabetes may have neuropathy or poor circulation of blood to
their feet.
d. I do not know
3. An early symptom of hypoglycemia (low blood glucose) is:
a. Frequent urination
b. Dry mouth and skin
c. Feelings of nervousness
d. I do not know
4. A symptom of hyperglycemia (high blood glucose) is:
a. Increased thirst
b. Low grade fever
c. Cool, clammy skin
d. I do not know
5. What is one cause of hypoglycemia?
a. Illness
b. Skipping a meal
c. Too little exercise
d. I do not know
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6. What is one cause of hyperglycemia?
a. Decreased food intake
b. Infection
c. Excessive insulin
d. I do not know
7. What is one cause of diabetic ketoacidosis?
a. Excessive exercise
b. Excessive intake of diet soft drinks over a prolonged period of time
c. Failure to take daily insulin dose(s)
d. I do not know
8. Which one of the following is the MOST appropriate initial action for a person
with diabetes to take if he/she feels that they are beginning to have a
hypoglycemic event?
a. Drink 4 ounces of orange juice
b. Drink 12 ounces of regular soda
c. Chew 1 glucose tablet
d. I do not know
9. James’ blood glucose is 240mg/dl and his urine is positive for ketones. What
should he do?
a. Call his doctor, test his blood glucose and urine every 2 hours for ketones
and continue his insulin or oral hypoglycemic agents
b. Omit his next dose of insulin or oral hypoglycemic agent and test his
blood glucose as he would normally do
c. Continue with his insulin or oral hypoglycemic agents and blood testing as
he normally would. These are normal results for individuals with diabetes
d. I do not know
10. What effect does illness have a person with diabetes’ insulin requirements?
a. Illness causes a decrease in insulin requirements
b. Illness causes an increase in insulin requirements
c. Illness causes no changes in insulin requirements
d. I do not know
11. Which of the following medications is known to increase blood glucose levels?
a. Acetaminophen
b. Ampicillin
c. Prednisone
d. I do not know
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12. Which of the following blood glucose values reflects a fasting blood glucose in
the normal range?
a. 50 mg/dl
b. 95 mg/dl
c. 155 mg/dl
d. I do not know
13. Type 2 diabetes is defined as a term for individuals who have insulin resistance
and usually have relative (rather than absolute) insulin deficiency.
a. True
b. False
14. A confirmed fasting plasma glucose value > 126 mg/dl is diagnostic for diabetes.
a. True
b. False
15. With medical nutrition therapy (MNT) for persons with diabetes no food is
forbidden and can be worked into an overall plan aimed at achieving as near
normal glucose levels as possible.
a. True
b. False
16. The “Rule of 15” implies treating low blood glucose with 15 grams of
carbohydrate and waiting15 minutes to recheck blood glucose.
a. True
b. False
17. To achieve and maintain glycemic goals and to reduce complications, self-monitoring
of blood glucose (SMBG) remains the most effective intervention.
a. True
b. False
18. Rapid acting insulin (Humalog/Novolog) should be given immediately before a meal as
this insulin begins to work in 5 minutes, peaks in about 1 hour and continues to work
for 3-4 hours.
a. True
b. False
19. How long can insulin be stored at room temperature?
a. One week
b. One month
c. 3 months
d. I do not know
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20. People with diabetes should check their urine for ketones when:
a. Their blood glucose is > 400
b. Their blood glucose is > 240
c. When they are ill
d. Both b and c
21. Which of the following is a physiological action of insulin?
a. Transports glucose across cell membranes for use by the cell
b. Stimulates the release of glucose stored in the liver
c. Enhances the breakdown of fats for energy
d. I do not know
22. Patients should be instructed to know when the type of insulin they take starts to work,
when it peaks and how long it lasts to prevent hypoglycemia.
a. True
b. False
Name: _____________________________________
Date Completed: _____________________________________
Supervisor: _____________________________________
Reminder: Once you have completed reading this study guide, go to:
http://www.surveymonkey.com/s.asp?A=68915169E36695
to do a brief evaluation of this learning tool.
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IX-5
B. Diabetes Study Guide Pretest/Post test (Answer Key)
1. What effect does exercise usually have on blood glucose?
a. Decreases blood glucose
b. Increases blood glucose
c. Has little effect on blood glucose
d. I do not know
2. Why is it necessary that individuals with diabetes take special care of their feet?
a. A number of years of injecting insulin into the thighs can cause edema in
both the legs and the feet.
b. Flat feet are commonly associated with diabetes unless preventive
measures are used routinely.
c. Persons with diabetes may have neuropathy or poor circulation of
blood to their feet.
d. I do not know
3. An early symptom of hypoglycemia (low blood glucose) is:
a. Frequent urination
b. Dry mouth and skin
c. Feelings of nervousness
d. I do not know
4. A symptom of hyperglycemia (high blood glucose) is:
a. Increased thirst
b. Low grade fever
c. Cool, clammy skin
d. I do not know
5. What is one cause of hypoglycemia?
a. Illness
b. Skipping a meal
c. Too little exercise
d. I do not know
6. What is one cause of hyperglycemia?
a. Decreased food intake
b. Infection
c. Excessive insulin
d. I do not know
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7. What is one cause of diabetic ketoacidosis?
a. Excessive exercise
b. Excessive intake of diet soft drinks over a prolonged period of time
c. Failure to take daily insulin dose(s)
d. I do not know
8. Which one of the following is the MOST appropriate initial action for a person
with diabetes to take if he/she feels that they are beginning to have a
hypoglycemic event?
a. Drink 4 ounces of orange juice
b. Drink 12 ounces of regular soda
c. Chew 1 glucose tablet
d. I do not know
9. James’ blood glucose is 240mg/dl and his urine is positive for ketones. What
should he do?
a. Call his doctor, test his blood glucose and urine every 2 hours for
ketones and continue his insulin or oral hypoglycemic agents
b. Omit his next dose of insulin or oral hypoglycemic agent and test his
blood glucose as he would normally do
c. Continue with his insulin or oral hypoglycemic agents and blood testing
as he normally would. These are normal results for individuals with
diabetes
d. I do not know
10. What effect does illness have a person with diabetes’ insulin requirements?
a. Illness causes a decrease in insulin requirements
b. Illness causes an increase in insulin requirements
c. Illness causes no changes in insulin requirements
d. I do not know
11. Which of the following medications is known to increase blood glucose levels?
a. Acetaminophen
b. Ampicillin
c. Prednisone
d. I do not know
12. Which of the following blood glucose values reflects a fasting blood glucose in
the normal range?
a. 50 mg/dl
b. 95 mg/dl
c. 155 mg/dl
d. I do not know
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13. Type 2 diabetes is defined as a term for individuals who have insulin resistance
and usually have relative (rather than absolute) insulin deficiency.
a. True
b. False
14. A confirmed fasting plasma glucose value > 126 mg/dl is diagnostic for diabetes.
a. True
b. False
15. With medical nutrition therapy (MNT) for persons with diabetes no food is
forbidden and can be worked into an overall plan aimed at achieving as near
normal glucose levels as possible.
a. True
b. False
16. The “Rule of 15” implies treating low blood glucose with 15 grams of
carbohydrate and waiting15 minutes to recheck blood glucose.
a. True
b. False
17. To achieve and maintain glycemic goals and to reduce complications, self-monitoring
of blood glucose (SMBG) remains the most effective intervention.
a. True
b. False
18. Rapid acting insulin (Humalog/Novolog) should be given immediately before a meal
as this insulin begins to work in 5 minutes, peaks in about 1 hour and continues to
work for 3-4 hours.
a. True
b. False
19. How long can insulin be stored at room temperature?
a. One week
b. One month
c. 3 months
d. I do not know
20. People with diabetes should check their urine for ketones when:
a. Their blood glucose is > 400
b. Their blood glucose is > 240
c. When they are ill
d. Both b and c
TARGET Diabetes Nursing Study Guide
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21. Which of the following is a physiological action of insulin?
a. Transports glucose across cell membranes for use by the cell
b. Stimulates the release of glucose stored in the liver
c. Enhances the breakdown of fats for energy
d. I do not know
22. Patients should be instructed to know when the type of insulin they take starts to work,
when it peaks and how long it lasts to prevent hypoglycemia.
a. True
b. False
Name: _____________________________________
Date Completed: _____________________________________
Supervisor: _____________________________________
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C. Insulin Injection Competency
Purpose:
To appropriately deliver an insulin injection.
Skills:
• Wash hands/wear gloves
• Inspect insulin/check expiration date/verify type, brand, dose
• Roll insulin between palms (cloudy insulin)
• Clean top of bottle with alcohol
• Pull plunger down to allow air into syringe (same number of units as insulin you
wish to withdraw)
• Push needle through rubber top of vial
• Push air into vial
• Turn vial upside down
• Pull plunger down to fill syringe with desired insulin amount
• Withdraw needle from vial
• Choose appropriate injection site
• Clean site with alcohol
• Pinch up skin
• Hold syringe like dart
• Quickly insert needle to full length, straight in, 90 degrees
• Push plunger smoothly and completely, release pinch
• Pull needle straight out
• Safely discard needle in sharps disposal container
• Record medication given/site of injection
Competency:
• Identify proper storage and appearance of insulin
• Identify proper rotation of sites
• State timing of insulin/meal schedule
Name: _________________________________
Date Completed: _________________________________
Supervisor: _________________________________
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D. Hypoglycemia Competency
Purpose:
To identify a hypoglycemic event and determine treatment.
Skills:
• Recognize symptoms of hypoglycemia
• Test blood glucose to confirm hypoglycemia
• Use Rule of 15 to treat hypoglycemia
• If blood glucose < 70 mg/dl, give 15 grams of carbohydrate
• Recheck blood glucose in 15 minutes
• If still < 70 mg/dl, treat with another 15 grams of carbohydrate
• Continue to treat until blood glucose > 70 mg/dl
Competency:
• Identify signs and symptoms of hypoglycemia
• Identify treatment of hypoglycemia
• Name 3 items containing 15 grams of carbohydrate
Name: _____________________________
Date Completed: _____________________________
Supervisor: _____________________________
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E. Glucometer Competency
Purpose:
To develop proficiency using glucometers.
To teach patients how to operate their own glucometer.
Skills:
Meter used for demonstration to be determined by individual clinical site.
Steps:
• Battery placement
• Coding of meter
• Check expiration date of test strips
• Load lancet into lancet device
• Wash hands
• Use proper technique for obtaining blood drop and applying to test strip
• Identify how and when to use glucose solution
• How to safely discard lancets
• Record results in blood glucose log book
Competency:
Demonstrate how to properly use meter, obtain blood sample and safely discard lancets
Name: _________________________
Date Completed: _________________________
Supervisor: _________________________
TARGET Diabetes Nursing Study Guide
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F. Monofilament Competency
Purpose:
• The filament applies 10 grams of pressure to a small point on the skin
• The filament is calibrated to bend when the 10 grams of force has been applied.
• If the patient does not feel the monofilament when you apply pressure to bend it,
sensation loss has occurred in that area.
• This should be performed annually on all diabetes patients.
• The American Diabetes Association and the Bureau of Primary Health Care’s
Lower Extremities Amputation Program (LEAP) recommend visual foot
exams/inspections at each visit.
Skills:
• Show the monofilament to the patient & demonstrate that it does not hurt. (touch
hand/arm with filament)
• Have patient turn head, close eyes or look at the ceiling.
• Ask patient to inform you when they feel the monofilament touching their foot.
• Hold monofilament perpendicular to the skin and use 3 second sequence
a) touch the skin at the areas indicated on the attached diagram
b) filament bends
c) lift from the skin
• Do not use rapid movement
a) use in random sequence
b) if patient does not say yes when a certain area is touched, continue on in
your sequence. After you have completed, return to the area that was
assessed as poor and repeat the test.
• Clean the filament between uses with a 1:10 bleach solution.
Competency:
Demonstrate how to perform monofilament testing with a patient.
Name: _______________________________
Date Completed: _______________________________
Supervisor: _______________________________
TARGET Diabetes Nursing Study Guide
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G. Insulin Pen Competency
Purpose:
Insulin pens provide an alternative insulin administration method to syringes and can
contribute to increased regimen adherence.
Skills:
• Wash hands
• Check expiration date of insulin
• Identify storage guidelines of specific insulin(s)
• Gently invert preparations of NPH, 70/30, and 75/25 to thoroughly mix; this
should be done 15-20 times
• Wipe rubber stopper with alcohol
• Apply needle by dialing 2 units and pushing through
• Prime the pen needle with two units of insulin
• Correctly dial dose
• Clean skin with alcohol
• Pinch skin
• Inject straight in 90 degrees
• Deliver dose, allow 5 seconds for injection to ensure complete insulin delivery
• Release pinch, pull pen straight out
• Check to see that dose knob is fully compressed
• Remove needle after use and dispose of needle in sharps disposal container
• Store the pen currently in use without the needle on at room temperature
Competency:
• State benefits of insulin pens to special populations
• Correctly prime, dial up and deliver dose
• Apply standard precautions with needle use, removal and proper disposal
Name: ________________________________
Date Completed: ________________________________
Supervisor: ________________________________
TARGET Diabetes Nursing Study Guide
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X. APPENDIX
A. Diabetes Summary
B. Pre-Diabetes
C. References
D. More Information
TARGET Diabetes Nursing Study Guide
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A. Diabetes Summary
1. Prevalence
• Over 18.2 million people – 6.3% of the population – have diabetes. Of this, it
is estimated that approximately 5.2 million people do not know they have the
disease. 16
• Approximately 93,395 Maine adults are estimated to have diabetes; 64,263
have been diagnosed; 32,132 have not yet been diagnosed. 17
2. Risk Factors (criteria for testing for diabetes)
• Age ≥ 45 yrs
• Overweight BMI ≥ 25
• Blood Pressure ≥ 140/90
• Abnormal Lipid Levels
o HDL < 35 mg/dl
o Triglyceride > 250 mg/dl
• Family History (first degree relative)
• Ethnicity
o African American
o Latino
o Native America
o Pacific Islander
• History of Gestational Diabetes
• Delivering a baby > 9 lbs
• On previous test had IGT or IFG
• Other clinical conditions associated with insulin resistance (acanthosis
nigricans)
• History of vascular disease
3. Signs and Symptoms of Hyperglycemia
• “Classic”
o polydipsia (increased thirst)
o polyuria (increased urination)
o unexplained weight loss
• Fatigue
• Polyphagia (increased hunger)
• Blurred vision
• Frequent infections
• Slow healing of cuts or sores
• Numbness/tingling of hands or feet
• Sexual problems
TARGET Diabetes Nursing Study Guide
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• Dry, itchy skin
• Frequently people are asymptomatic
4. Diagnostic Criteria
• The Fasting Blood Glucose (FBG) is the preferred diagnostic test. Diabetes is
diagnosed with FBG ≥ 126 mg/dl.
• Casual blood glucose (any time of day) > 200 mg/dl with symptoms of
hyperglycemia.
• Oral Glucose Tolerance Test (OGTT) with blood glucose results > 200 mg/dl
two hours after 75 gram glucose load is given.
Note: All tests need to be repeated to confirm the diagnosis.
Note: For both diabetes and pre-diabetes, testing should be considered at an
earlier age or done more frequently for overweight individuals that have
other risk factors noted above.
5. Classification
• Type 1 diabetes – auto-immune; beta cell destruction leading to absolute
insulin deficiency; only 5-10% of those diagnosed with diabetes.
• Type 2 diabetes – characterized by insulin resistance, combined with a relative
insulin deficiency; accounts for approximately 90% of people living with
diabetes.
• Gestational diabetes – diabetes during pregnancy.
• Secondary diabetes (tumors, trauma, surgery, or infection of the pancreas).
6. Diabetes is managed through:
• Meal Planning
• Physical Activity
• Medications
• Home blood glucose monitoring
• Detection and prevention of acute and chronic complications
• Managing stress
• Community resources (web sites, support groups)
• Prevention for family members (Get the word out!)
• Education is key. Knowing how to care for yourself with diabetes is the
critical factor in preventing complications and ensuring a long and productive
life.
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B. Pre-Diabetes – We need to treat it now!
1. Prevalence
According to the American Diabetes Association (ADA) it is estimated that
approximately 41 million Americans have pre-diabetes. 18
2. Risk Factors (criteria for testing for pre-diabetes)
• Age ≥ 45 yrs
• Overweight BMI ≥ 25
• Blood Pressure ≥ 140/90
• Abnormal Lipid Levels
o HDL < 35 mg/dl
o Triglyceride > 250 mg/dl
• Family History (first degree relative)
• Ethnicity
o African American
o Latino
o Native America
o Pacific Islander
• History of Gestational Diabetes
• Delivering a baby > 9 lbs
• On previous test had IGT or IFG
• Other clinical conditions associated with insulin resistance (acanthosis
nigricans)
• History of vascular disease
Note: For both diabetes and pre-diabetes, testing should be considered at an
earlier age or done more frequently for overweight individuals that have
other risk factors.
3. Symptoms
None
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4. Diagnosis
• The Fasting Blood Glucose (FBG) is the preferred diagnostic test.
Pre-diabetes is diagnosed with an Impaired Blood Glucose (IBG) of
>100 mg/dl but < 126 mg/dl.
• Impaired Glucose Tolerance (IGT) is determined by doing an Oral Glucose
Tolerance Test (OGTT) with blood glucose results = to 140-199 mg/dl two
hours after a 75 gram glucose load is given.
5. Treatment = Life Style Changes
• Increase physical activity
• Decrease portion sizes for meals and snacks
• Decrease fats
• Increase fruits and vegetables
• Weight loss
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C. References
American Diabetes Association website – www.diabetes.org
A Core Curriculum for Diabetes Education, American Association of Diabetes Educators,
2001.
American Diabetes Association; Michigan Diabetes Research and Training Center; Life
with Diabetes, 1997.
American Diabetes Association; Clinical Practice Recommendations, 2004.
“An Inside Look at Preventing Diabetes Complications”; 2000, Channing L. Bete
Company, Inc.
Diabetes Control and Complications Trial (DCCT); NIDDK, NIH, National Diabetes
Information Clearinghouse, website www.niddk.org
Joslin Diabetes Center, “The Joslin Guide to Diabetes”.
Aspen Medical & Nutrition Therapy, Margaret Powers.
Diabetes Health, July & August, 2004 editions.
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D. For More Information…..
1. General Information
American Diabetes Association
www.diabetes.org
Centers for Disease Control
www.cdc.gov/diabetes
Diabetes Mall
www.diabetes.net
Diabetes Self-Management
www.diabetesselfmanagement.com
International Diabetes Center
Minneapolis, MN
www.parknicollet.com/diabetes
MaineHealth
www.MaineHealth.org
Michigan Diabetes Research & Training Center
National Institutes for Health
www.niddk.nih.gov
Will provide free pamphlets at patient’s request on multiple topics such as
foot care, digestive problems (gastroparesis), neuropathy, coronary artery
disease, etc.
2. Subscriptions
Diabetes Forecast
Diabetes Self-Management
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3. Topic Specific Information
Diabetes Disease Process & Treatment
American Diabetes Association (www.diabetes.org)
Medications
• Oral medication by typing in the medication name
followed by .com (example: www.avandia.com)
• For insulin, use the brand name such as Lilly or Novolin.com
• All Pharmaceutical web sites
Complications
Retinopathy
• American Academy of Opthamology
www.aao.org
Vascular Disease
• Vascular Disease Foundation
www.vdf.org
Nephropathy
National Kidney Foundation
www.kidney.org
Neuropathy
• The Neuropathy Trust
www.neuropathy-trust.org
Nutritional Management
Lilly Pamphlet “Nutrition in the Fast Lane”
American Dietetic Association
www.eatright.org
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Monitoring Blood Glucose
Patient specific home glucose monitor website
Ex: One Touch Basic, Sure Step, One Touch Ultra & One Touch UltraSmart are
produced by LifeScan, please see www.LifeScan.com
Physical Activity
American Diabetes Association
www.diabetes.org
go into search and put in “exercise”
Joslin Diabetes Center
www.joslin.org
go under beginner’s guide to diabetes and click on “exercise basics”
Psychological Adjustment
See “Local Support Groups” list available from the Maine Diabetes Prevention
and Control Program (DCPC) at (207) 287-5180 or by visiting their website:
http:www.maine.gov/dhhs/bohdcfh/dcp/DPCPhome.htm
Patient Assistance Program
www.needymeds.com
TARGET Diabetes Nursing Study Guide
XI-1
XI. END NOTES
_________________
1A Core Curriculum for Diabetes Education; “Diabetes and Complications”; Marion J. Franz, MS, RD, LD,
CDE, Editor; 2003, pg. 5.
2American Diabetes Association Clinical Practice Recommendations, Supplement1, Jan. 2005, p. S5.
3A Core Curriculum for Diabetes Education; “Diabetes Education and Program Management”; Marion J.
Franz, MS, RD, LD, CDE, Editor; 2003, pg. 71.
4American Diabetes Association/Michigan Diabetes Research & Training Center “Life with Diabetes”, pg
62-63.
5.American Diabetes Association: Clinical Practice Recommendations, Supplement 1, 2005, p S12. .
6 A Core Curriculum for Diabetes Education; “Diabetes Management Therapies”; Marion J. Franz, MS,
RD. LD, CDE; 2003; pg.67.
7 A Core Curriculum for Diabetes Education; “Diabetes Management Therapies”; Marion J. Franz, MS,
RD, LD, CDE; 2003, pgs. 70-71.
8 American Diabetes Association Clinical Practice Recommendations, Vol. 27, Supplement 1, Jan. 2005,
p. S11.
9 American Diabetes Association Clinical Practice Recommendations, Vol. 28, Supplement 1, 2005, p S10.
10 Yale Diabetes Center, “Diabetes Facts & Guidelines”, Silvio E. Inzucchi, MD, 2002-2003, pg. 35.
11 Diabetes Health, “Byetta Now Available for Type 2s”; Daniel Trecroci, July, 2—5, pg 36-37.
12 Diabetes Forecast, “Is There a Place for Alcohol in Your Diabetes Meal Plan?”; Madelyn L. Wheeler,
MS, RD, FADA, CDE; August, 2003.
13Gehling, Eve, The Next Step: Depression, Newsflash, Diabetes Care and Education Practice Group of the
American Dietetic Association, Fall 2001, Vol. 22, No. 5, p.20.
14 A Core Curriculum for Diabetes Education, 4th Edition; “Diabetes Education and Program Management”;
American Diabetes Association; Marion J. Franz, MS, RD, LD, CDE Editor; 2001; pp 34 & 74.
15Adapted from the Maine Guide for Preconception Care of Women with Established Diabetes.
16American Diabetes Association, 2004; www.diabetes.org
17Department of Health and Human Services, Maine Bureau of Health, Diabetes Prevention and Control
Program, Health Fact Sheet: Diabetes in Maine, January, 2005.
18American Diabetes Association, 2004; www.diabetes.org
High-Alert Medications and Safe Practices
A s t u d y g u i d e f o r n u r s e s Marla Husch, RPh Jennifer M. Groszek, RN, BSN, MJ
Denise Rooney, RN, BSN, OCN
High-Alert Medications and Safe Practices: A study guide for nurses iii
CONTENTS
About the authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
General safety principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Intravenous heparin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Potassium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Magnesium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Phosphorus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Intravenous calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Sodium chloride 3% (hypertonic saline) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Warfarin (Coumadin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Neuromuscular blocking (paralytic) agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Chemotherapy agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Exercise answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Nursing education instructional guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Instructions for obtaining your nursing contact hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Nursing education exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
Nursing education evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
High-Alert Medications and Safe Practices: A study guide for nurses 3
The following safety principles are applicable to the administration of all medications:
• Two unique patient identifiers should be assessed prior to administering medications. Reliable choices
include those on the wristband or those that the patient can verbalize, such as name, age/date of
birth, and medical record number. Never use room number or location as an identifier.
• Allergy status is assessed prior to administration.
• The nurse understands the medication’s intended purpose and ensures the “Five Rights”:
1. Right patient
2. Right dose
3. Right route
4. Right frequency
5. Right time
• The nurse documents in a timely manner having checked the five rights.
• The patient is informed of the drug, dose, potential side effects, and any relevant laboratory values.
• “Read back and verify” is performed by anyone receiving a telephone or verbal order.
• Only hospital-approved abbreviations, acronyms, and symbols are used in documentation.
• Many medications have distinctive colors. However, never rely on color to identify a medication.
• Any medication error, near miss, or adverse drug reaction should be reported according to your
institution’s incident report system policy.You may also report systems (e.g., pumps, dispensing systems,
human systems, etc.) that appear vulnerable to error so that they can be improved.
• Consult the pharmacy as a reference for questions.
• Syringes not prepared at the bedside are labeled with the name of the medication and dose.
• A double check system is often used with the administration of certain high-alert medications.
Double checks require two clinicians to independently calculate the dose without reviewing prior
calculations.This can ensure
1. detection of error before it reaches a patient
2. early identification of systems vulnerable to human error so that they can be improved1
General safety principles
4 High-Alert Medications and Safe Practices: A study guide for nurses
General safety principles
Reference
1. The road less traveled. Huntingdon Valley, PA. Institute for Safe Medication Practices. 2002 August 21.
High-Alert Medications and Safe Practices: A study guide for nurses 5
Why are opioids identified as high-alert medications?
Opioids bind with opiate receptors at many sites in the central nervous system (e.g., brain, brain stem,
spinal cord, etc.) and peripheral nervous system, and thereby alter both the perception of and emotional
response to pain. If they are prescribed, administered, or monitored inappropriately, respiratory depression,
coma, and even death can result.
As you read this section, keep in mind these commonly reported problems associated with opioids:
• Misconceptions about addiction, tolerance, dependence, and allergies.
• Misunderstandings regarding equianalgesic dosing of opioids.
• Infusion pump errors with Patient Controlled Analgesia (PCA) and Patient Controlled Epidural
Analgesia (PCEA) are frequent.1
• Oral liquid versions of morphine and oxycodone are available in many concentrations. Mix-ups
among them have led to serious overdoses.2
• Allergic reactions occur frequently.3
• Errors related to the drug, concentration, and route.
• Confusion between hydromorphone, morphine, and oxycodone:
- Hydromorphone intravenous (IV) is five times more potent than morphine IV
- Oral hydromorphone is about three times more potent than oxycodone
• Families and friends push the PCA or PCEA button, which can lead to serious overdoses.4
• Patients receiving opioids may not be adequately monitored.This is critical during the first 24 hours
and at night because nocturnal hypoxia occurs most frequently during these periods.5
• Confusion has occurred between sustained-release and immediate-release products (e.g., Oxycontin
and oxycodone).
Opioids
6 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Back pain
Below is a case study about a patient who was at risk for overdose because of inappropriate dosing and
administration of morphine.
A 58-year-old man with chronic lower back pain is admitted to your unit with a PCA after a laminectomy.
His PCA orders read “morphine 2 mg every eight minute bolus with no basal dose.” He was taking Norco
(one tablet every six hours) at home for several months prior to the surgery. He is complaining of severe
pain, and you notice that his wife is pressing the button on the PCA. What is wrong with this picture?
Source: Northwestern Memorial Hospital Pain Expert Nurse Newsletter (November 2002).
• First, the bolus on a PCA should not be set at eight minutes. Remember that the peak effect of
most intravenous opioids is 15 minutes, so boluses given more frequently can lead to accumulation
of the drug and potential sedation. Eventually, such accumulation can lead to respiratory depression.
• Second, determine the patient’s previous opioid dose. Norco, or 10 mg of hydrocodone, is approximately
equal to 10 mg of oral morphine.The patient was taking four doses each day, or 40 mg,
which is approximately equal to 40 mg of oral morphine or 13.3 mg of parenteral morphine.Thus,
the best method of replacing his previous opioid dose would be to convert the 13 mg of parenteral
morphine into a basal rate of approximately 0.5 mg per hour. Contact your pharmacy for assistance.
• Third, to determine whether the bolus dose is correct, ask the patient how much relief he obtains
with the 2 mg. If the pain is relieved 100% and he is sedated, then reduce the bolus. If the pain is
relieved 100% and he is not sedated, the dose is correct. And if the relief is less than 100%, even
with the addition of the basal rate, then increase the bolus dose. Normally we use 50%–100% of
the hourly rate, which would be 0.25 mg–0.5 mg. But this dose only replaces his previous Norco
dose. Reassessment is critical to determine the effective dose.
• Fourth, educate the patient’s wife about the dangers of anyone other than the patient pushing the
button on the PCA pendant. Most family members or friends will be responsive. Consult the physician
and consider a care conference if they continue to interfere.
High-Alert Medications and Safe Practices: A study guide for nurses 7
Opioids
Nursing implications
Administration
• Opioids may be administered through a variety of routes: oral, transdermal, rectal, and parental
(which includes IV, subcutaneous (SQ), epidural, and intrathecal).
• Although some pain medications are prescribed to be administered intramuscularly, this method is
not recommended because the absorption is highly variable. Contact the physician to determine
alternative routes that may be available.8
• Prior to administration, assess baseline
- pain level
- sedation level
- respiratory status
• Verify established opioid use prior to initiating an opioid regimen.
• Assess for treatment contraindications, such as concomitant opioids that have the same duration
of action.
• Contact pharmacy regarding potential incompatibility concerns with IV analgesic medications.
• Assess the need for an appropriate bowel regimen to help prevent constipation.
Critical thinking
• Is the current regimen providing relief to the patient’s satisfaction?
• Does the patient or the patient’s family have misconceptions about opioid use? (e.g, fear of
addiction, tolerance, dependence, etc.)6
• Does the patient have unrealistic expectations of pain control?
• Does a pharmacist need to be consulted?
• Are there any new complaints or physical assessment changes that may relate to the use of
the pain medications?
• Is there an appropriate bowel regimen prescribed?
• Does the patient have undesirable past experiences with the use of opioids (e.g., effectiveness,
adverse effects, history of substance abuse, etc.)?7
• Are there concomitant orders for medications that contain acetaminophen? (If so, monitor
for total daily doses of acetaminophen.)
• If a PCA is ordered for a patient, is the patient a suitable candidate based on his or her level
of consciousness, psychological reasons, or intellectual capacity?
• All opioids are not equianalgesic. For example, 2 mg IV hydromorphone is approximately equal to
10 mg IV morphine.
• Opioids, even at appropriate doses, can suppress respiration, heart rate, and blood pressure.
Frequent monitoring is therefore essential.9
Monitoring
• Use a pain intensity scale to assess patient’s response to treatment. (For further guidance, refer to
Exhibit 1.1 on p. 12)
• Monitor “PRN” (as needed) use. Decreasing use may indicate decreasing pain, and orders may need
to be adjusted.10
• Monitor
- respiratory status
- sedation level
- nausea/vomiting
- bowel/bladder function
(For additional guidance on monitoring and assessing respiratory status and sedation level, use the
sample sedation scale and respiratory rate monitoring guidelines in Exhibit 1.2 on p. 13 for additional
guidance.)
• Monitor total daily acetaminophen intake for patients taking combination opioid products (e.g.,
patients with normal liver function should not receive greater than 4000 mg/day.) (To review the
aceteaminophen content of several common preparations, refer to Exhibit 1.3 on p. 14.)
• Dosing should be reevaluated if the cause or focus of the pain changes (e.g., postoperative, postprocedure,
etc.) or is removed (e.g., tubes, renal stones, etc.).
Oral opioids
• Sustained-release oral medications cannot be crushed or split.
• When reviewing medication orders, be vigilant for similar trade and generic names. For example,
• Oral liquid opioids are available in various concentrations, which can be stored in proximity to each
8 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Roxanol is morphine (immediate release, liquid)
Roxicodone is oxycodone (immediate release)
and
MS Contin is morphine (long-acting)
OxyContin is oxycodone (long-acting)
High-Alert Medications and Safe Practices: A study guide for nurses 9
Opioids
other. For example, Roxicodone is available in 5 mg/mL bottles or 20 mg/mL bottles.
• Be aware that potencies of IV and oral preparations are not equianalgesic. For example, 30 mg of
oral morphine is approximately equal to 10 mg IV/SQ morphine.
• Note products that combine an opioid and acetaminophen (refer to Exhibit 1.2 on p. 13):
- Norco contains hydrocodone 10 mg/acetaminophen 325 mg
- Vicodin contains hydrocodone 5 mg/acetaminophen 500 mg
• Watch for concomitant orders for acetaminophen, such as
- Tylenol Extra Strength, 1–2 tablets po every 6 hours PRN
- Norco, 1–2 tablets po every 4 hours PRN
• The total daily dose of acetaminophen should not exceed 4000 mg in patients with normal
liver function.
Transdermal opioids
• Remove old patches prior to placing new ones (when appropriate) on alternate sites (e.g., flat sites
such as the back or chest are best).
• Treat topical patches like any other medication: chart on the Medication Administration Record
when it was administered and on what site.11
• Medication from transdermal patches can be absorbed to a much greater extent in patients with
elevated body temperatures (e.g., from a warming blanket or fever).This can lead to significant
overdoses.12
PCA
• PCA infusions are always used in conjunction with a maintenance intravenous fluid.
• It is recommended that PCA cartridge concentrations be standard throughout an institution. For
example, only 1 mg/mL and 0.2 mg/mL are available for use. It is also recommended that colored
labels differentiate these concentrations. However, do not rely only on color to differentiate.
• The button should never be pushed by anyone else, including friends or family members.13
• Educate patients about the proper use of PCA before initiation. Start during the preoperative testing
visit so that patients are not too groggy to understand.14
• PCA tubing should be changed if there is a medication change or concentration change.
• The pump history should be cleared only if there is a medication change, such as morphine to
hydromorphone. If there is only a concentration change, such as hydromorphone 0.2 mg/mL to
hydromorphone 1 mg/mL, the history should not be cleared.
• It is recommended that two registered nurses check and verify the PCA pump settings at time of
initiation and/or change in dose, medication, concentration, or medication cartridge.
• Research shows that double checks are most effective when conducted independently.15
10 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
PCEA
• PCEA is contraindicated in patients receiving low molecular weight heparin or fibrinolytic therapy.
• No other medications should be infused through the epidural line.
• If a bolus dose is administered through the epidural catheter, the nurse should stay at the bedside
during and for five minutes following administration of the bolus dose.
• To avoid overdosing, the maximum bolus volume should not exceed the current hourly rate
of infusion.
• The epidural catheter may be left in place after discontinuing the infusion. A lock is placed at the distal
end of the catheter and does not need to be flushed.The epidural space is free space and is not
prone to clotting.
• It is recommended that two registered nurses check and verify the PCEA pump settings at the time
of initiation and/or change in dose, medication, concentration, or medication cartridge.
• Research shows that double checks are most effective when conducted independently.16
IV opioids
• Verify the concentration on the pharmacy label.
• Calculate the continuous infusion rate and independently check with another nurse or pharmacist.
• Never use a continuous infusion rate for acute pain of a limited duration.17
• When assessing the need for a possible change in the hourly continuous infusion rate, consider the
total usage (including number of bolus doses used) over at least the previous 12 hours. If only the
first few hours are considered, the need for an increase in the hourly rate may appear falsely elevated
as many times more boluses are required at the initiation of pain control medication until steadystate
is achieved.
• To prevent overdosing, bolus doses are preferred to increases in the hourly continuous infusion rate
to treat episodic or sporadic pain.18
Exercise
Your patient’s current pain medication orders are as follows:
Tylenol Extra Strength 1–2 tablets po every 6 hours PRN and Norco 1–2 tablets po every 4 hours PRN
It is 2100 and the patient has already received two tablets of Tylenol Extra Strength at 0100, 0700, and
1600 that day. He also has received Norco (two tablets at 1200 after physical therapy).The patient is now
requesting two more tablets of Norco before he goes to sleep. What should you do?
Answer provided on p. 57.
High-Alert Medications and Safe Practices: A study guide for nurses 11
Opioids
Summary points
• Errors associated with opioids are among the most commonly reported incidents that lead to
patient harm. Overdoses have occurred due to
- confusion between different opioids because of sound-alike names.
- anyone other than the patient pushing the button on the PCA or PCEA.
- the fact that even at appropriate doses, opioids can suppress respiration, heart rate, and
blood pressure. Frequent monitoring is therefore essential.
- failure to monitor total daily amounts of acetaminophen intake, which can lead to severe
liver damage.
• Independent double checks are recommended for rate calculations and infusion pump programming
so that errors can be identified prior to administration.
12 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Exhibit 1.1 Patient pain-assessment tool
• It is important to let your doctors and nurses know when you are in pain.
• Point to where the pain is located.
• Describe how the pain feels (e.g., aching, throbbing, or burning).There may be many ways to
describe your pain.
• Rate your pain on a scale of 0–10, with 0 meaning no pain and 10 meaning the worst pain
you could imagine.
Wong-Baker FACES pain rating scale
0 1 2 3 4 5 6 7 8 9 10
NO PAIN MODERATE PAIN WORST PAIN
Source:Wong D.L., Hockenberry-Eaton M.,Wilson D.,Winkelstein M.L., Schwarz P.:Wong’s Essentials of Pediatric Nursing ed. 6, St. Louis, 2001,
p. 1301. Copyright Mosby, Inc. Reprinted with permission.
High-Alert Medications and Safe Practices: A study guide for nurses 13
Opioids
Exhibit 1.2 Sedation scale and respiratory rate monitoring guidelines
Sedation scale
S Sleeping Normal sleep, respiration rate > 8 per minute
0 None Alert, awake
1 Mild Responds to normal voice
2 Moderate Responds to loud voice/shaking
3 Severe Somnolent, difficult to arouse
Sensory motor checks
Patient-controlled analgesia (PCA)
Sedation scale and respiratory rate:
every two hours for 24 hours, then every
four hours thereafter.
Epidural and patient-controlled
epidural analgesia (PCEA)
Sedation scale and respiratory rate:
every two hours for 24 hours, then every
four hours thereafter.
Same monitoring frequency following initiation
of epidural infusion, after a bolus,
and/or increase in rate.
If bupivacaine is used, check lower extremities every two hours, while awake, for the first 24
hours.
0 Normal strength and sensation
1 Weak but able to bend knees and ankles, normal sedation
2 Unable to bend knees, normal sensation
3 Unable to move legs, decreased sensation
• Monitor blood pressure every hour for four hours, then every four hours thereafter
• Check orthostatic blood pressure prior to ambulating
14 High-Alert Medications and Safe Practices: A study guide for nurses
Opioids
Exhibit 1.3 Acetaminophen hepatoxicity
It is necessary to monitor the total acetaminophen intake for patients taking combination opioid
products.The oral adult analgesic dose of acetaminophen is 325 mg–1000 mg.The total daily dose
should not exceed 4000 mg. Recognition of the quantities of acetaminophen provided by various
combination analgesic products can help to prevent unintended ingestion of potentially toxic doses.
The following table details the acetaminophen content of several common preparations.
1Although effective for many types of moderate to severe pain, combination agents have a maximum or ceiling dose
due to the acetaminophen.Thus,Vicodin Extra Strength® and Darvocet N-100® are not recommended, as their
acetaminophen content is high.
It is best to use only one of these agents at a time. When these agents are prescribed at close to
the maximum acetaminophen dose, it is necessary to inform patients not to use acetaminophen
containing over-the-counter (OTC) analgesics, sinus/allergy medicine, or cough-cold remedies.
Source: Reprinted with permission from Michael Fotis, M.A. (Ed). Optimizing medication use at NMH: Suggested guidelines for commonly
encountered problems. Chicago: Northwestern Memorial Hospital, 2003.
TRADE NAME
Vicodin®
Vicodin Extra Strength®1
Darvocet N-100®1
Norco®
Tylenol®
Tylenol Extra Strength®
Tylenol #3®
Tylenol #4®
Percocet-5/325®
ACETAMINOPHEN
CONTENT
500 mg
750 mg
650 mg
325 mg
325 mg
500 mg
300 mg
300 mg
325 mg
NUMBER OF
TABLETS/CAPSULES
TO REACH 4 G/DAY
8
5
6
12
12
8
13
13
12
OPIOID
Hydrocodone 5 mg
Hydrocodone 7.5 mg
Propoxyphene 100 mg
Hydrocodone 10 mg
Not applicable
Not applicable
Codeine 30mg
Codeine 60 mg
Codeine 5 mg
High-Alert Medications and Safe Practices: A study guide for nurses 15
Opioids
References
1. M.R. Cohen and C.M. Kilo. “High-alert medications: Safeguarding against errors.” In M.R. Cohen (Ed.),
Medication Errors.Washington, DC: American Pharmaceutical Association, 1999.
2. Ibid.
3. Ibid.
4. Ibid.
5. “Safety issues with patient-controlled analgesia.” Huntingdon Valley, PA: Institute for Safe Medication
Practices (ISMP), 2003 July 10.
6. M. Fotis, M.A. (Ed.) Optimizing medication use at NMH: Suggested guidelines for commonly
encountered problems. Chicago: Northwestern Memorial Hospital, 2003.
7. Ibid.
8. J. Paice. “Alternative to intramuscular pain medication.” Northwestern Memorial Hospital Pain Expert
Nurse Newsletter. 2003 January.
9. “More on avoiding opiate toxicity.” Huntingdon Valley, PA: ISMP, 2002 May 29.
10. See note 6 above.
11. “Serious consequences if patches are not removed.” Huntingdon Valley, PA: ISMP, 2003 June 26.
12. “Elevated skin and body temperatures.” Huntingdon Valley, PA: ISMP, 2003 June 30.
13. “Safety issues with patient-controlled analgesia.” Huntingdon Valley, PA: ISMP, 2003 July 10.
14. See note 8 above.
15. “Maybe Santa’s on to something.” Huntingdon Valley, PA: ISMP, 2001 December 12.
16. Ibid.
17. See note 6 above.
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