Version: / 1
Author: / Prepared by Nursing Matters and Associates.
Date: / 10th May 2016
Next Formal Review date: / May 2019
Authorised by:
1.0 Policy Statement.
It is the policy of [the Centre] that residents with Diabetes will be cared for according to an individual assessment of needs, wishes and preferences and a person centred care plan underpinned by evidence based practice.
2.0 Purpose.
The purpose of this policy is to outline the process and procedures for providing care and services to any resident with diabetes.
3.0 Scope.
This policy applies to all staff involved in the provision of care to residents with diabetes including registered nurses, healthcare assistants and kitchen staff.
4.0 Definitions.
4.1 Diabetes.
Diabetes, also known as diabetes mellitus is a long-term condition caused by too much glucose in the blood. Diabetes is categorized into the following two types:
4.1.1 Type 1 diabetesoccurs when the body produces no insulin. It is also referred to as referred to as insulin-dependent diabetes. It can sometimes be referred to as juvenile diabetes or early-onset diabetes because it usually develops before the age of 40, often during the teenage years. Type 1 diabetes is far less common than type 2 diabetes. People with type 1 diabetes make up only 10% of all people with diabetes
4.1.2 Type 2 diabetesoccurs when not enough insulin is produced by the body for it to function properly, or when the body's cells do not react to insulin. This is called insulin resistance. Type 2 is the commonest type of diabetes.
5.0 Responsibilities
Actions
/Responsible Person.
This policy will be disseminated to and read by all clinical staff involved in caring for residents.
/Person in Charge [or specify other person]
A record will be kept of all those who have signed the policy acknowledgement forms.
/ Person in Charge [or specify other person]Where a new version of this policy is produced, the previous version will be removed and filed away.
/ Person in Charge [or specify other person]An explanation of this policy will be given to all new nursing staff, care assistants involved in the direct care of individual residents.
/ Person in Charge [or specify other person]Nurses and healthcare assistants will be provided with the opportunity to attend training /updates on management of diabetes where there is a significant change to practice in this area.
/ Person in Charge [or specify other person]The admitting and/ or designated nurse for each resident will ensure that resident’s conditions and medical diagnosis are identified on admission.
/Admitting nurse and/or designated nurse.
Where a resident has a BMI>25 on admission and has not been screened for diabetes, the residents GP will be contacted regarding the need for screening for diabetes.
/Admitting nurse and/or designated nurse.
Each resident with diabetes will have an assessment and care plan individual to their needs and preferences as outlined in this policy.
/Admitting nurse and/or designated nurse.
Nurses will maintain their competence in the care of residents with diabetes and communicate any competency / knowledge deficits to the Person in Charge [or specify other person].
/All registered nurses
Care given to residents will be in accordance with the plan of care developed and agreed by the resident and / or representative and other healthcare professionals involved in the resident’s care.
/All healthcare staff providing care to residents.
Changes in a resident’s condition will be reported to the senior nurse in charge [or specify other person e.g. clinical nurse manager] and changes to care will be communicated to all relevant healthcare professionals.
/All nurses, healthcare assistants and other healthcare professionals involved in the resident’s care.
It is the responsibility of all healthcare assistants to make known to the nurse on duty any changes to the resident’s condition that may indicate a that that the resident may be experiencing hypo or hyperglycaemic episode. /All healthcare assistants
6.0 Assessment and Care Planning for Residents with Diabetes.
5.1 Assessment.
5.1.1 All prospective residents to [the Centre] must have a pre-admission assessment completed prior to admission. This may be carried out at the resident’s home, at the referring facility or over the phone, with a nurse from the referring facility. The purpose of the pre-admission assessment is to gather information that will enable [the Centre] make a decision as to whether or not the home will be able to meet the resident’s needs. The pre-admission assessment includes collection of information about disease diagnosis and therefore will identify any resident who has an existing diagnosis of diabetes.
5.1.1 On admission to [the Centre], each new resident will have a person centred assessment using [enter details of admissions assessment], which is repeated formally every four months. Reassessment in any or more than one activity of living is triggered by a change in the resident’s condition affecting specific activities of living.
5.1.2 Each residents assessment of needs related to a diagnosis of diabetes should be included under the relevant section of the assessment form [specify section].
5.1.3 Where any resident has a Body Mass Index (BMI) of ≥ 25kg/m² and there is no record of the resident having been screened for diabetes, the nurse should liaise with the resident’s GP re same.
5.1.4 Where a resident with a BMI of ≥ 25kg/m² has had a normal diabetes screen, it is recommended that the resident should be screened every three years. (HSE, 2008; National Medicines Information Centre, 2011).
5.1.5 Where a resident has a BMI of ≥ 25kg/m² and has additional risk factors, it is recommended that screening be undertaken more frequently. These additional risk factors include:
■ Hypertension.
■ Existing arterial disease.
■ Inactivity.
■ HDL cholesterol level <0.90mmol/l and /or triglyceride level of >2.82mmol/l.
■ On previous testing had impaired Glucose tolerance or fasting glucose.
(Health Services Executive, 2008).
5.1.6 Additionally, the nurse should be aware of any signs or symptoms that may indicate that the resident has diabetes. These include:
■ increased thirst
■ passing large amounts of urine or incontinence
■ extreme tiredness
■ blurred vision
■ weight loss
■ itching of the genitals
■ recurrent candiasis, skin or urine infections or wounds failing to heal.
(Guidelines and Audit Implementation Network, 2010).
5.1.7 With regard to the above symptoms, it is important to note that the classic osmotic symptoms of diabetes, such as thirst and passing large amounts of urine are usually less prominent in older people, due to the increased renal threshold for glucose.
5.1.8 Because diabetes can be asymptomatic in up to 50% of older people, the nurse should also be aware of non-specific symptoms such as being generally unwell, fatigued, or lethargic, which are common manifestations of diabetes in old age.
5.1.9 Geriatric syndromes may be the first manifestation of diabetes in a resident such as falls and urinary incontinence. Symptoms could also be atypical, such as anorexia, rather than the typical polyphagia.
5.1.2 Where a resident presents with any one or a combination of the above symptoms and there is no known cause, the nurse should liaise with the resident’s GP regarding the need for screening for diabetes.
5.2 Care Planning for Residents with Diabetes.
5.2.1 Each resident in [the centre] will have an individualized care plan specific to their needs, wishes and preferences.
5.2.2 For residents who do not have a diagnoses of diabetes, but have risk factors, the care plan should identify any interventions required to prevent diabetes and to monitor for signs and symptoms of diabetes. These interventions will vary according to each resident and will be identified and included in the care plan. These may, include, for example:
■ Monitoring and management of weight as required and as directed by a dietician.
■ Monitoring blood pressure and management of hypertension as required and directed by the resident’s GP.
■ Dietary needs as required based on the resident’s nutrition assessment and as directed by a dietician.
■ Exercise needs as required.
■ Routine blood lipid monitoring where this is required and ordered by the resident’s GP.
■ Blood glucose and urinalysis monitoring, which again would be identified and included in the care plan for special treatments and procedures.
■ Management of hypoglycaemic episodes.
5.2.3 For residents with diabetes, the care plan should address all needs identified from the comprehensive assessment of all activities of living.
5.2.4 The residents understanding of their illness and ability to be involved in decision making should be outlined in the cognition care plan [or specify other appropriate care plan].
5.2.5 The residents information needs and / or education needs and how these will be met should be outlined under the care plan for communication.
5.2.6 Particular reference to the following should be included in the relevant care plans:
■ Nutrition and dietary needs.
■ Skin and pressure area care.
■ Foot care.
■ On- going monitoring needs, such as blood glucose monitoring and urinalysis.
■ Medication needs.
■ Management of Hypoglycaemia.
5.3 Nutrition Care Plan.
5.3.1 The resident’s nutrition care plan must be individualized to each resident as outlined in [the Centres] Nutrition and Hydration Policy. For those with diabetes, the nutrition care must also include:
■ Any specific dietary requirements related to their diabetes.
■ Any instructions regarding nutrition from an attending dietician or diabetic clinic.
■ The resident’s involvement in the nutrition care plan.
5.4 General Dietary Guidance for Residents with Type 2 Diabetes.
5.4.1 Residents should be encouraged and facilitated to eat regular meals at regular times each day. Have a breakfast, a lunch or tea type meal and a dinner.
5.4.2 A portion of starchy carbohydrate food such as bread, cereal, potato, rice or pasta, at the appropriate portion should be included at each meal.
5.4.3 Sugar does not need to be omitted from the diet, but should be limited and should include low sugar alternatives, such as:
■ Artificial sweeteners can be added to drinks, cereals and puddings
■ Preserves such as reduced sugar jams and marmalade
■ Sugar-free diet drinks
■ Fruit tinned in natural juice rather than syrup
■ Plain biscuits, e.g. one digestive, 2 Marietta biscuits.
■ Sugar-free or reduced sugar puddings
5.4.4 Fat intake should be reduced and the type of fat should be changed to unsaturated fats.
5.4.5 Residents should be encouraged to eat fruit and vegetables regularly, a total of 5 portions of a mix of fruit and vegetables every day.
5.4.6 Eating fish twice a week is recommended, white fish once a week and oily fish once a week.
5.4.7 Avoid adding salt to food and cut down on processed foods.
5.4.8 Low fat snacks are recommended e.g. fruit or a diet yogurt.
5.4.9 Residents should be encouraged to drink 8-10 glasses of fluid per day, unless the resident is on fluid restriction.
5.4.10 More detailed guidance from INDI (2012) booklet Healthy eating for people with type 2 diabetes in the nurses’ office.
(Irish Nutrition and Dietetic Institute (2012 and the Guidelines and Audit Implementation Network, Northern Ireland, 2010).
5.1 Skin Care.
5.1.1 Residents with diabetes may be more prone to pressure sores because of reduced awareness of pressure and dry skin. Risk factors arising from diabetes are included in [the Waterlow Risk Assessment tool/ Braden assessment – specify which one is in use in the Centre], which is completed for each resident on admission, four monthly or in accordance with need.
5.1.2 Where a resident is at risk of developing a pressure sore or skin tears the skin condition care plan should include interventions to prevent these as outlined in [the Centre’s] Wound management Policy.
5.1.3 Residents with diabetes may also be more prone to skin conditions including bacterial and fungal infections and itching as well as other skin conditions. People with high glucoseThe food you eat gets digested and broken down into a sugar your body's cells can use. This is glucose, one of the simplest forms of sugar.X levels tend to have dry skin and less ability to fend off harmful bacteria. Both conditions increase the risk of infection. Information about skin conditions related to diabetes are detailed in Appendix 2.
5.1.4 Several kinds of bacterial infections occur in people with diabetes:
■ Sty’s (infections of the glands of the eyelid)
■ Boils Folliculitis (infections of the hair follicles)
■ Carbuncles (deep infections of the skin and the tissue underneath)
■ Infections around the nails.
5.1.1 For residents with diabetes, the skin condition care plan should include any additional observations required to prevent skin damage and pressure sores.
5.1.5 The resident’s skin condition care plan should include the need to observe for and report any signs of inflamed skin, such as areas that are hot, swollen, red, and painful or changes to the resident’s skin condition.
5.1.6 The skin condition care plan for a resident with diabetes should include the resident’s daily skin care needs. Resident’s with diabetes may have additional skin care needs including:
■ The need to keep skin clean and dry. Talcum powder may be used in areas where skin touches skin, such as armpits and groin.
■ It is recommended that resident’s with diabetes avoid very hot baths and showers.
■ Dry skin or itchy skin can lead to scratching and cause the skin to open up and allow infection to set in. Soap should be avoided where possible, as it tends to dry the skin further. If soap is to be used, it should ideally be unperfumed and rich in moisturisers. Bubble bath is not recommended for those with dry skin.
■ A soap substitute, such as aqueous cream is preferable to soap as it can be applied to the body and rinsed off with water or used on a sponge or flannel.
■ Washing water should not be too hot as the heat tends to dry the skin further, but it should be warm enough to be comfortable
■ Moisturising lotions should be used to prevent or treat dry skin. While total emollient therapy may be required for dry skin, lotions should not be used between toes as the extra moisture there can encourage fungus to grow.