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.
Related Topics
Privacy Policy, Terms and Conditions, DMCA Policy and Compliant
Copyright © 2018-2023 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.