Diabetic Management

1. PURPOSE:

 1.1 To provide IHHC staff with information to manage residents with diabetes and limit any adverse effects
   and complications from this disease.
 1.2 To promote patient safety.

2. POLICY:

 2.1 All residents with a diagnosis of diabetes will receive the appropriate monitoring of their Blood Glucose
   Levels and receive the correct and timely administration of medications prescribed to treat this disease.

3. DEFINITION:

 3.1 Diabetes Mellitus - the commonest form of diabetes, caused by a deficiency of the pancreatic hormone
   insulin, which results in a failure to metabolize sugars and starch. Sugars accumulate in the blood and
   urine, and the by-products of alternative fat metabolism disturb the acid–base balance of the blood,
   causing a risk of convulsions and coma.
 3.2 Diabetes Insipidus – a rare form of diabetes caused by a deficiency of the pituitary hormone
   vasopressin, which regulates kidney function.
 3.3 Diabetes Type 2 – is a long term metabolic disorder that is characterized by high blood sugar, insulin
   resistance and relative lack of insulin.
 3.4 Diabetes Type 1 – is a form of diabetes mellitus that results from the autoimmune destruction of the
   insulin-producing beta cells in the pancreas.

4. PROCEDURE:

 4.1 Preparation:
   4.1.1 Nurses must not mix different insulins’ in the same syringe for administration to reduce risk of
   administration errors.
   4.1.3 Document the advanced preparation of insulin on the Multi-Disciplinary note ensuring full details
   are recorded, including batch number, type of insulin and expiry date are recorded.
 4.2 Equipment:
   4.2.1 Sharp box
   4.2.2 Insulin syringes 30; 50 or 100 units’ syringes (depending on which is most appropriate for the
   dose), needle length should be more than 8 millimeters (8mm).
 4.3 Explain procedure to patient / family.
   4.3.1 Wash hands.
   4.3.2 Prepare equipment and re-suspend (by rocking back and forth) insulin at least 20times if using
   cloudy insulin. Do not shake as you will damage the insulin suspension. If using a clear insulin there is
   no need to re-suspend.
   4.3.3 Swab insulin vial with an alcohol wipe and allow drying.
   4.3.4 Draw up insulin in presence of patient as follows for each syringe using a clean procedure to
   prevent contamination:
      4.3.4.1 Remove needle cover and pull back plunger to measure an amount of air equivalent to
      the amount of insulin prescribed.
      4.3.4.2 With insulin vial standing upright, insert the needle through the centre of the rubber cap
      and push down plunger. Invert the insulin vial.
   4.3.5 Pull back plunger until slightly more than correct dose is drawn up. Expel any air bubbles back into
   vial.
   4.3.6 Re-check correct prescribed dose has been drawn up and remove needle from vial.
   4.3.7 Carefully re-sheath needle (there is no risk of contaminated needle stick injury as needle is sterile
   – in event of a needle stick injury the syringe must be safely discarded).
   4.3.8 Label each syringe with patient name, insulin name, date of preparation, initials of RN.
   4.3.9 Label each container with patient name, insulin name, insulin dose, time of administration, number
   of syringes, date, name and signature of registered nurse.
   4.3.10 Store pre-filled syringes with needles slightly elevated, within a labeled container as described
   earlier in main body of the fridge (away from freezer section or the back of the fridge).
   4.3.11 Dispose of clinical waste and wash hands.
   4.3.12 Complete nursing notes ensuring date, time, insulin type/dose, batch number and number of
   syringes pre-filled are recorded.
   4.3.13 If any pre-loaded syringes have not been used within the designated period, they must be
   disposed of.
 4.4 Storage
   4.4.1 Any insulin remaining in vial after 28 days should be discarded.

5. RESPONSIBILITY:

 5.1 This policy covers all RN’s employed by Island Home Health Care who are required to treat patients with
   diabetes mellitus within their own home.
 5.2 It is the responsibility of every IHHC employed RN who is required to treat patients with diabetes mellitus
   to be familiar with this policy and procedure.
 5.3 Home Care Considerations
   5.3.1 Assist the patient in deciding whether to reuse insulin syringe at home. The patient may decide to
   do so due to cost; however, reuse has become controversial because the newer, finer needles may
   become dull or bent after one or two injections, causing tearing of tissue, which can lead to
   lipodystrophy
      5.3.1.1 Needles should not be reused if painful injection or irritated sites results
      5.3.1.2 Needle should be recapped by patient and stored in a clean place if it is going to be
      reused
   5.3.2 Assist the patient in obtaining the appropriate syringe size and needle length for injections
      5.3.2.1 Determine if there are visual or dexterity issues that make a syringe with gradations
      farther apart more desirable.
      5.3.2.2 There is no medical reason to use needles > 8mm in length, even in obese patients.
      Needle lengths of 4, 5, and 6 mm are reliable to deliver medication into the subcutaneous space.
      To prevent inadvertent intramuscular injection in patients who are thin, the needle can be
      inserted at a 45-degree angle (rather than at a 90-degree angle) and/or the skin should be folded
      prior to needle insertion
   5.3.3 Advice the patient that it is not necessary to use alcohol to wipe off the top of the vial or prepare
      the skin before injection; it has not proved to result in lower rate of infection and adds cost and
      time to the procedure. The patient should maintain good hygiene.
   5.3.4 Instruct the patient to store insulin currently in use in a clean, secure place away from direct
      sunlight and heat. In-use insulin does not require refrigeration. Check manufacturer
      recommendations for when to discard insulin vials and pens; recommendations may vary from 10
      to 28 days after opening. All unopened vials/pens must be stored in the refrigerator until initial
      use.
   5.3.5 Check manufacturer’s recommendations before teaching the patient how to mix insulin; for
      example, the patient should know that insulin glargine and insulin determir must never be mixed
      with any other insulin. Always countercheck with manufacturers’ websites containing
      recommendations’ are Aventis
   5.3.6 Avoid prefilling syringes if at all possible because manufacturers have no data on the stability of
      insulin stored in syringes for long periods. If prefilling is the only option, store in refrigerator or
      suggest an insulin pen injection device
   5.3.7 Help the patient develop a plan for the disposal of
      needles. There are no federal regulations for discarding needles used at home; however,
      needles and lancets can pose a risk for injury. Refer to Health and Safety, “Safe Disposal of
      Sharps” (IHHC PCI P&P/M-0008).

6. APPENDICES - NIL

 6.1 Finger Stick Procedure for Blood Glucose Monitoring
   6.1.1 Prepare the finger to be lanced by having the patient wash hands in warm water and soap. Dry
   thoroughly. For convenience, an alcohol wipe may be used to cleanse the finger. Alcohol must dry
   thoroughly before finer is lanced. (See Hand Washing Procedure, IHHC P&P/M-0007).
   6.1.2 Don disposable gloves
   6.1.3 Turn on the glucose meter and place a test strip in the machine when the machine is ready. Watch
   the indicator for placing the blood to the strip.
   6.1.4 Select a site for the blood sample, usually the inside tip of the middle or fourth (ring) finger. If
   needed, warm the hands by running them under warm water or rubbing them together to help improve
   blood flow.
   6.1.5 Clean the site with the alcohol prep pad and wait until the alcohol evaporates. Prick the patient’s
   finger lateral to the fingertip using lancet/lancing device, obtaining a drop of blood large enough to
   satisfy the requirements of the testing strips being used. Almost all glucose meters available today
   require very small amounts, ranging from 0.3 microliters to 4 microliters
   6.1.6 Place the drop of blood on or at the side of the strip. Make sure the strip “blood window” is full of
   blood, if not the reading may be inaccurate
   6.1.7 The glucometer will take a few moments to calculate the blood sugar reading. Follow the doctor's
   orders for whatever the blood sugar reading is. Make sure to record the results.
   6.1.8 The lanced finger is covered with gauze or a tissue until bleeding subsides. If necessary, an
   adhesive bandage is then applied.
   6.1.9 Put the lancet in an impervious (Sharps) container with a tight-fitting lid. This type of container is
   leak proof and cannot be punctured by sharp objects.
   6.1.10 Hold paper towel, alcohol prep pad and test strip in gloved hand, take off one glove at a time,
   turning gloves inside out as they are taken off. Place gloves in a lined, covered trash can or seal inside
   a baggie. Wash hands with soap and warm running water.

7. REFERENCES:

 7.1 National Patient Safety Agency (2010) Rapid response Report. Safer Administration of Insulin.
   NPSA/2010/RRR013
 7.2 Nettina, S.M. (2014) Lippincott Manual of Nursing Practice, 10th edition

8. CROSS REFERENCE

 8.1 IHHC/PAI/0015/15