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MANAGEMENT OF HOSPITALIZED DIABETIC PATIENTS
At any one time, 10% to 20% of general medical-surgical patients in the hospital have diabetes. This number may increase as elderly patients make up a greater proportion of the population. Al-though some hospitals may have a specialized diabetic/metabolic unit, typically patients with diabetes are admitted throughout the hospital.
Often diabetes is not the primary medical diagnosis, yet prob-lems with the control of diabetes frequently result from changes in the patient’s normal routine or from surgery or illness. Some of the main issues pertinent to nursing care of the hospitalized di-abetic patient are presented in the following section.
All patients admitted to the hospital must relinquish control of some aspects of their daily care to the hospital staff. For the patient with diabetes who is actively involved in diabetes self-management (especially insulin dose adjustment), relinquishing control over meal timing, insulin timing, and insulin dosage may be particularly difficult. The patient may fear hypoglycemia and express much concern over possible delays in receiving attention from the nurse if hypoglycemic symptoms occur.
It is important for the nurse to acknowledge the patient’s con-cerns and to involve the patient as much as possible in the plan of care. If the patient disagrees with certain aspects of the nursing or medical care related to diabetes, the nurse must communicate this to other members of the health care team and, where appro-priate, make changes in the plan to meet the patient’s needs. The nurse and other health care providers need to pay particular at-tention to patients who are successful in managing self-care, assess their self-care management skills, and encourage them to con-tinue their self-care management if correct and appropriate.
Hyperglycemia may occur in the hospitalized patient as a result of the original illness that led to the need for hospitalization. In addition, a number of other factors may contribute to hyper-glycemia, such as:
· Changes in the usual treatment regimen (eg, increased food, decreased insulin, decreased activity)
· Medications (eg, glucocorticoids such as prednisone, which are used in the treatment of a variety of inflammatory dis-orders)
· IV dextrose, which may be part of the maintenance fluids or may be used for the administration of antibiotics and other medications
· Overly vigorous treatment of hypoglycemia
· Mismatched timing of meals and insulin (eg, postmeal hyper-glycemia may occur if short-acting insulin is administered immediately before or even after meals)
Nursing actions to correct some of these factors are important for avoiding hyperglycemia. Assessment of the patient’s usual home routine is important. The nurse should try to approximate as much as possible the home schedule of insulin, meals, and activities. Monitoring blood glucose levels has been identified by the ADA as an additional “vital sign” essential in assessing the pa-tient’s status (ADA, Bedside Blood Glucose Monitoring in Hos-pitals, 2003). The results of blood glucose monitoring provide information needed to obtain orders for extra doses of insulin (at times when insulin is usually taken by the patient), an important nursing function. The insulin doses must not be withheld when blood glucose levels are normal.
Short-acting insulin is usually needed to avoid postprandial hyperglycemia (even in the patient with normal premeal glucose levels), and NPH insulin does not peak until many hours after the dose is given. IV antibiotics should be mixed in normal saline (if possible) to avoid excess infusion of dextrose (especially in the patient who is eating). It is important to avoid overly vigorous treatment of hypoglycemia, which may lead to hyperglycemia. Treatment of hypoglycemia should be based on the established hospital protocol (usually 15 g carbohydrate in the form of juice, glucose tablets, or, if necessary, 0.5 to 1 ampule of 50% dextrose administered intravenously). Extra sugar should not be added to the juice. If the initial treatment does not increase the glucose level adequately, the same treatment may be repeated.
Hypoglycemia in a hospitalized patient is usually the result of too much insulin or delays in eating. Specific examples include:
· Overuse of “sliding scale” regular insulin, particularly as a supplement to regularly scheduled, twice-daily short- and intermediate-acting insulins
· Lack of dosage change when dietary intake is changed (eg, in the patient taking nothing by mouth)
· Overly vigorous treatment of hyperglycemia (eg, giving too-frequent successive doses of regular insulin before the time of peak insulin activity is reached) so that there is an accu-mulated effect
· Delayed meal after administration of lispro or aspart insulin (patient should eat within 15 minutes of administration)
Nurses must assess the pattern of glucose values and avoid giving doses of insulin that repeatedly lead to hypoglycemia. Successive doses of subcutaneous regular insulin should be ad-ministered no more frequently than every 3 to 4 hours. For patients receiving NPH or Lente insulin before breakfast and dinner, the nurse must use caution in administering supplemental doses of regular insulin at lunch and bedtime. Hypoglycemia may occur when two insulins peak at similar times (eg, morning NPH peaks with lunchtime regular insulin and may lead to late-afternoon hypoglycemia, and dinnertime NPH peaks with bedtime regular insulin and may lead to nocturnal hypoglycemia). To avoid hypo-glycemic reactions caused by delayed food intake, the nurse should arrange for a snack to be given to the patient if meals are going to be delayed because of procedures, physical therapy, or other activities.
Dietary modifications common during hospitalization require special consideration when the patient has diabetes.
For the patient who must have nothing by mouth in preparation for diagnostic or surgical procedures, the nurse must ensure that the usual insulin dosage has been changed. These changes may include eliminating the regular insulin and giving a decreased amount (eg, half the usual dose) of intermediate-acting NPH or Lente insulin. Another approach is to use frequent (every 3 to 4 hours) dosing of regular insulin only. IV dextrose may be ad-ministered to provide calories and to avoid hypoglycemia.
Even when no food is taken, glucose levels may rise as a re-sult of hepatic glucose production, especially in patients with type 1 diabetes and lean patients with type 2 diabetes. Further, in type 1 diabetes, elimination of the insulin dose may lead to the development of DKA. Thus, administering insulin to the pa-tient with type 1 diabetes who is NPO is an important nursing action.
For patients with type 2 diabetes who are taking insulin, DKA does not develop when insulin doses are eliminated because the patient’s pancreas produces some insulin. Thus, skipping the in-sulin dose altogether when the patient has type 2 diabetes (and is receiving IV dextrose) may be safe; however, close monitoring is essential.
For patients who are NPO for extended periods, glucose test-ing and insulin administration should be performed at regular in-tervals, usually two to four times per day. Insulin regimens for the patient who is NPO for an extended period may include NPH insulin every 12 hours (with regular insulin added to the NPH, depending on the results of glucose testing) or regular insulin only every 4 to 6 hours. These patients should receive dextrose infusions to provide some calories and limit ketosis.
To prevent these problems resulting from the need to with-hold food, diagnostic tests and procedures and surgery should be scheduled early in the morning if possible.
When the diet is advanced to include clear liquids, the diabetic patient will be receiving more simple carbohydrate foods, such as juice and gelatin desserts, than are usually included in the diabetic diet. It is important for hospitalized patients to maintain their nu-tritional status as much as possible to promote healing. Thus, the use of reduced-calorie substitutes such as diet soda or diet gelatin desserts would not be appropriate when the only source of calo-ries is clear liquids. Simple carbohydrates, when eaten alone, cause a rapid rise in blood glucose levels; thus, it is important to try to match peak times of insulin with peaks in glucose. If a pa-tient was receiving insulin at regular intervals while NPO, the scheduled times for glucose tests and insulin injections must be changed to match meal times.
Tube feeding formulas contain more simple carbohydrates and less protein and fat than the typical diabetic diet. This results in increased levels of glucose in the diabetic patient receiving tube feedings. It is important that insulin doses be administered at reg-ular intervals (eg, NPH every 12 hours or regular insulin every 4 to 6 hours) when tube feedings are administered at a continuous rate. If insulin is administered at routine (prebreakfast and predinner) times, hypoglycemia during the day may result from patients receiving more insulin without more calories, and hy-perglycemia may occur during the night when feedings continue but insulin action decreases.
A common cause of hypoglycemia in patients receiving con-tinuous tube feedings and insulin is inadvertent or purposeful dis-continuation of the feeding. The nurse must discuss with the medical team any plans for temporarily discontinuing the tube feeding (eg, when the patient is away from the unit). Planning ahead may allow alterations to be made in the insulin dose, or it may allow for IV dextrose to be administered. In addition, if problems with the tube feeding develop unexpectedly (eg, the pa-tient pulls out the tube, the tube clogs, or the feeding is discon-tinued when residual gastric contents are found), the nurse must notify the physician, assess blood glucose levels more frequently, and administer IV dextrose if indicated.
The patient with diabetes receiving parenteral nutrition may re-ceive both IV insulin (added to the parenteral nutrition container) and subcutaneous intermediate- or short-acting insulins. If the patient is receiving continuous parenteral nutrition, the blood glucose level should be monitored and insulin administered at regular intervals. If the parenteral nutrition is infused over a lim-ited number of hours, subcutaneous insulin should be adminis-tered so that peak times of insulin action coincide with times of parenteral nutrition infusion.
The nurse caring for a hospitalized diabetic patient must focus attention on oral hygiene and skin care. Because diabetic patients are at increased risk for periodontal disease, it is important for the nurse to assist patients with daily dental care. The patient may also require assistance in keeping the skin clean and dry, especially in areas of contact between two skin surfaces (eg, groin, axilla, and, in obese women, under the breasts), where chafing and fungal infections tend to occur.
For the bedridden diabetic patient, nursing care must empha-size the prevention of skin breakdown at pressure points. The heels are particularly susceptible to breakdown because of loss of sensation of pain and pressure associated with sensory neuropathy.
Feet should be cleaned, dried, lubricated with lotion (but not between the toes), and inspected frequently. If the patient is in the supine position, pressure on the heels can be alleviated by elevating the lower legs on a pillow, with the heels positioned over the edge of the pillow. When the patient is seated in a chair, the feet should be positioned so that pressure is not placed on the heels. If the patient has a foot ulcer, it is important to provide pre-ventive foot care to the unaffected foot as well as to carry out spe-cial care of the affected foot.
As always, every opportunity should be taken to teach the pa-tient about diabetes self-management, including daily oral, skin, and foot care. Female diabetic patients should also be instructed about measures for the avoidance of vaginal infections, which occur more frequently when blood glucose levels are elevated. Pa-tients often take their cues from the nurse and realize the impor-tance of daily personal hygiene if this is emphasized during their hospitalization.
As mentioned earlier, physiologic stress, such as infections and surgery, contributes to hyperglycemia and may precipitate DKA or HHNS. Emotional stress may have a negative impact on dia-betic control as well. An increase in stress hormones leads to an increase in glucose levels, especially when the intake of food and insulin remains unchanged. In addition, during periods of emo-tional stress, the person with diabetes may alter the usual pattern of meals, exercise, and medication. This contributes to hyper-glycemia or even hypoglycemia (eg, in the patient taking insulin or oral antidiabetic agents who stops eating in response to stress).
People who have diabetes must be made aware of the poten-tial deterioration in diabetic control that can accompany emo-tional stress. They must be encouraged to try to adhere to the diabetes treatment plan as much as possible during times of stress. In addition, learning strategies for minimizing stress and coping with stress when it does occur are important aspects of diabetes education.
People with diabetes are living longer; therefore, both type 1 and type 2 diabetes are seen more frequently in the elderly popula-tion. Regardless of the type or duration of diabetes, the goals of diabetes treatment may need to be altered when caring for the el-derly. The focus is on quality of life issues, such as maintaining independent functioning and promoting general well-being. Al-though striving for strict blood glucose control may not be safe or appropriate, prolonged symptomatic hyperglycemia should be avoided.
Some elderly patients cannot manage a detailed diabetes treat-ment plan, but the nurse must not assume that all patients older than a certain age can adhere only to the simplest regimen. Al-though the goal may be simply to avoid hypoglycemia and symp-tomatic hyperglycemia, certain patients may prefer more complex regimens that allow more flexibility in meals and daily schedule. As with all people with diabetes, individualization of the treatment plan with frequent follow-up by the health care team is important.
Some of the barriers to learning and self-care that may be seen in the elderly include decreased vision, hearing loss, memory deficits, decreased mobility and fine motor coordination, increased tremors, depression and loneliness, decreased financial resources, and limitations related to other medical illnesses. Assessing pa-tients for these barriers as well as discussing any misconceptions or folk beliefs regarding the cause and treatment of diabetes is important in setting up a diabetes treatment plan and educational activities. Presenting brief, simplified instructions with ample op-portunity for practice of skills is important. The use of special de-vices such as a magnifier for the insulin syringe, an insulin pen, or a mirror for foot inspection is helpful. If necessary, family members and other community resources are called on to assist with diabetes survival skills. It is preferable to teach patients or family members to test blood glucose at home; the choice of meter should be tailored to the patient’s visual and cognitive sta-tus and dexterity. Frequent evaluation of self-care skills (insulin administration, blood glucose monitoring, foot care, diet planning) is essential, especially in patients with deteriorating vision and memory.
Dietary adherence is difficult for some elderly patients because of decreased appetite, poor dentition, and decreased physical and financial ability to prepare meals. In addition, patients may be unwilling to change long-standing dietary habits. Altering the meal plan to incorporate these eating habits or other limitations may be necessary.
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