Introduction Diabetes mellitus is a chronic disabling disorder which is increasing in prevalence.

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1 Introduction mellitus is a chronic disabling disorder which is increasing in prevalence. To enhance diabetes care this organisation acknowledges the importance of its staff cooperating with the specialist health professionals delivering the diabetic service. The wellbeing and quality of life sustained by the individual will be enhanced by well-planned, comprehensive care and support of staff. Many people live with diabetes for many years and it is important that their views and the way they manage their diabetes is incorporated, wherever possible into their diabetic care plan. Liaison with community diabetes care service Regular liaising with the community diabetes team is important for staff to ensure they are up to date with the treatment being given, the assessed risk of hypoglycaemia and other complications for each individual. The specialist nurse can provide advice and support, to both the individual and staff. Other community-based healthcare professionals, e.g. dietician, podiatrist, and pharmacist, can provide important contributions to optimising diabetes care. Procedure Diet and Nutrition Diet plays an important part in controlling diabetes. All individuals will have a menu and diet plan in place from the diabetic nurse. Both catering and care or support staff involved in preparing food will work with the individual and follow this plan. The individual s choice and preferences will always be taken into consideration in the preparation of agreed diets. If the individual continually refuses and chooses other foods the worker must record and report immediately to their supervisor or manager who may need to contact other professionals for guidance. When working with individuals it is their choice which foods they eat and this organisation will provide both individual and their family with information and support to encourage a healthy diabetic diet and work with health care professionals to this end. All individuals are screened for malnutrition. The MUST tool is used for this purpose. The presence of co-existing disease may lead to physical and cognitive impairment in an individual with diabetes and can make activities such as eating difficult or impossible, and place the individual at nutritional risk. This organisation will work with a dietician, the speech and language team (SALT) and GP or hospital specialist as required. The healthcare professional provides time and advice about nutrition and physical activity appropriate to the needs of the person with diabetes. Care or Support plan Within their main care or support plan each individual will have an individualised diabetes care or support plan. Revision May / 9

2 The agreed objectives summarised in the diabetes care plan will include; diet, foot care, eye care, wellbeing review arrangements, medication and the need for regular medication review. The individual is encouraged to be fully involved in this care plan along with relevant health professional. For those individuals assessed as lacking the capacity to make a decision a best interest decision will be made concerning the management of medication and the diabetes following the Mental Capacity Act 2005 Code of Practice At each care planning consultation the healthcare professional(s) gives the individual the opportunity to: share information about issues and concerns share results of biomedical tests discuss the experience of living with diabetes and address needs to manage obesity, food and physical activity receive help to access support and services agree a plan for managing diabetes address individual priorities and goals identify priorities and/or goals that are jointly agreed including jointly setting a goal for HbA1c identify detailed specific actions in response to identified priorities which include an agreed timescale Care planning incorporates: nutritional advice discussing psychological wellbeing managing obesity structured education screening for complications smoking cessation advice physical activity Expert Individuals Programme agreeing goals for HbA1c agreeing plans for managing diabetes discussing goals Review arrangements of the diabetic care plan Each individual with diabetes requires documented evidence of a review. The frequency of the review should be decided with the healthcare professional or diabetic nurse. This review will also include measures of walking ability, balance, mood assessment, and cognitive function. Foot care services NICE guideline on diabetic foot problems [NG19} Individuals with diabetes are continually monitored and the individual s current risk of developing a diabetic foot problem is assessed Revision May / 9

3 Low risk: no risk factors present except callus alone Moderate risk: deformity neuropathy non-critical limb ischaemia High risk: previous ulceration previous amputation on renal replacement therapy neuropathy and non-critical limb ischaemia together neuropathy in combination with callus and/or deformity non-critical limb ischaemia in combination with callus and/or deformity Active diabetic foot problem: ulceration spreading infection critical limb ischaemia gangrene suspicion of an acute Charcot arthropathy an unexplained hot, red, swollen foot with or without pain Any assessed risk must be reported within 24 hours to the health care professional responsible for their diabetic care and a risk assessment and care plan review put in place to mitigate the risk. Individuals with a limb threatening or life threatening diabetic foot problem are referred immediately to acute services. The NICE guideline on diabetic foot problems (recommendation 1.4) defines the following as limb threatening and life threatening diabetic foot problems: ulceration with fever or any signs of sepsis ulceration with limb ischaemia gangrene All individuals with diabetes should have and will be encouraged to have regular visits by or to a chiropodist to ensure any problems associated with diabetes are picked up as soon as possible. If these visits cannot be arranged by the individual or their family they will be arranged by this organisation Transport and or an escort service will be arranged as required. Staff are not permitted to cut the nails of the individual. Staff must report any changes to the skin or problems identified by the individual immediately and appropriate pressure relieving aids put in place as required. Revision May / 9

4 redness to the skin signs of bruising pain feeling of numbness to the area skin breakdown Well being Depression is more common in people with long-term conditions but may go unnoticed in older people with complex health problems such as diabetes. Painful neuropathy, foot ulceration and adverse effects of medication can all contribute to depression. We recognise that anything which affects the service user s mental well-being may also affect their ability to successfully manage their own diabetes. Staff are trained to recognise symptoms of depression, so that an early diagnosis can be made by the GP and this will help limit the longer term impact. Screening at the start of the service and at least annually is carried out. Definitions Psychological problems in people with diabetes may include: depression anxiety injection related anxieties fear of hypoglycaemia eating disorders problems coping with diagnosis Eye care services Individuals with diabetes are likely to have a high incidence of eye disease this may include macular disease, cataract and refractive error. All individuals will be supported to attend appointments at eye clinics as required or be encouraged to have annual eye tests. An escort service will be arranged as required. Staff must report any concerns, changes or problems in the individual s eye sight immediately to their manager or supervisor. Management of infections We recognise that our individuals with diabetes are at increased risk of a range of infections including skin, respiratory, oropharyngeal, and urinary tract. Observing for signs of infection such as a change in mobility, increased confusional state, or worsening lethargy staff are aware of the need to report these signs immediately so that the appropriate medical help can be sought quickly. Vaccination programme We recognise that individuals with diabetes are a high-risk group for influenza and other serious infections. Each individual is encouraged to receive timely vaccinations to reduce risk of serious infections, such as the pneumococcal and influenza vaccinations. The vaccination schedule is included in their care plan along with any other relevant evidence. Revision May / 9

5 Blood glucose monitoring The following items of equipment are available: a blood glucose monitoring machine which is regularly standardised; provision of suitable blood glucose reagent strips and a sharps disposal box Wherever possible people with diabetes should be encouraged to self-monitor their blood glucose level and adjust their own treatment. Where this is not possible staff will be required to take on this task. All staff carrying out this procedure will be trained and competent. We encourage individuals with diabetes to agree and document a target HbA1c with their healthcare professional and receive ongoing review of treatment to minimise hypoglycaemia. Equipment Blood glucose monitor Test strips Control solution Single-use safety lancet Non sterile gloves Cotton wool/low linting gauze Sharps box Procedure Turn on the machine and ensure the correct time and date are presented on the screen and that there is adequate battery life Where applicable scan in or enter operator number or bar code on name badge Check the unit of measure and ensure it is reading mmol/l prior to each use (units of measure may change from mmol/l to mg/dl which could result in incorrect readings) Check reagent strips are in date and have not been exposed to the air. Check the individual s details, explain the procedure and gain consent. Ask the individual to wash their hands and dry with clean gauze Wash your hands and put on gloves Take a single use lancet and if it has depth settings ensure the correct settings the middle one) (usually The usual site for lancing is the side of the distal segment of the third or fourth finger, ideally on the less dominant hand as they are less calloused. The area should be pink and warm and free from callouses, cuts, bruises, burns or previous punctures. Tips and pads of fingers should be avoided as with a more dense nerve supply they can be more painful Activate the single use device/lancet as per manufacturers guidelines at the chosen site Ensure the site of piercing is rotated, avoiding frequent use of index finger or thumb The finger tips may require milking from palm of hand towards fingers to gain a large enough droplet of blood but avoid milking the finger alone Insert testing strip into blood glucose monitor and apply the first drop of blood to the testing strip - some strips are dosed/filled from the side instead of dropping blood directly onto the strip. Revision May / 9

6 Ensure that the window of the test strip is entirely covered. Place gauze over puncture site to prevent infection Remove gloves and place in clinical waste Read the result from the monitor, document and sign records Report any unexpected results to ensure appropriate treatment When monitoring blood glucose levels 50% of errors are due to insufficient blood on the test strip which leads to falsely low readings. Out of date or incorrectly stored test strips are also a common cause of incorrect readings. If errors persist ask a colleague to repeat the test and if continues get the monitor checked. Medication We ensure that people with diabetes are able to agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance. Administration of treatments including insulin Regular review of medication using a care plan takes place to ensure that treatment is tailored to the individual and is associated with maximal health gain and minimal adverse effects. Where required individuals are supported to continue administering their own insulin. When this is no longer possible the nurse will administer the insulin as per MAR chart. We ensure adequate staff training in initiating and managing insulin therapy within a structured programme. Hyperglycaemia (hyper) This happens when blood glucose levels are too high - usually above 7 mmol/l before a meal and above 8.5 mmol/l two hours after a meal. There are several reasons why this may happen. It may be that: a medication dose has been missed more carbohydrate than the body and/or the medication can cope with have been eaten the individual is stressed the individual is unwell from an infection a recent hypo has been over treated Symptoms may include: passing more urine than normal, especially at night being very thirsty headaches tiredness and lethargy Treating hyperglycaemia (hypers) Treatment of hypers will depend on what has caused them, if the blood glucose level is high for a short time, emergency treatment won t be necessary but if it stays high take the following action: encourage the individual to drink plenty of sugar-free fluids the individual may need to take extra insulin Revision May / 9

7 If the individual is feeling unwell, especially if they are vomiting, contact the diabetes healthcare team for advice as necessary How to prevent a hyperglycaemia ensure the individual is aware of their carbohydrate portions and how they may affect their blood glucose levels continue administering diabetes medication as prescribed wherever possible when the individual is feeling ill, or not eating and contact your diabetes healthcare team encourage the individual to keep active Review diabetic care plan regularly involving the individual and a member of the specialized health care team. Diabetic Ketoacidosis Consistently high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA). This happens when a severe lack of insulin means the body cannot use glucose for energy, and the body starts to break down other body tissue as an alternative energy source. Ketones are the by-product of this process. Ketones are poisonous chemicals which build up and, if left unchecked, will cause the body to become acidic - hence the name 'acidosis'. Early symptoms In the early stages, the main signs of diabetic ketoacidosis are: high blood glucose levels: DKA is often (but not always) accompanied by high blood glucose levels, if your levels are consistently above 15 mmol/l you should check for ketones in the blood/urine ketones are easily detected by a simple urine or blood test, using strips available on prescription passing large amounts of urine severe thirst feeling sick tiredness abdominal (tummy) pain shortness of breath Left untreated, more advanced symptoms can develop, such as: rapid heartbeat (tachycardia) rapid breathing, where you breathe in more oxygen than your body actually needs (hyperventilate) vomiting dizziness a smell of ketones on your breath, which can smell like pear drops or nail varnish remover confusion drowsiness or loss of consciousness This is a medical emergency and medical help must be called immediately Revision May / 9

8 Hypoglycaemia (hypo) Hypoglycaemia means low blood glucose levels - less than 4 mmol/l*. This is too low to provide enough energy for your body s activities. Symptoms Hypos can come on quickly and everyone has different symptoms, but common ones are: feeling shaky, sweating, hunger, tiredness, blurred vision, lack of concentration, headaches, feeling tearful, stroppy or moody, going pale. There s no rule as to why they happen, but some things make it more likely: excess insulin, delayed or missed meal or snack, not enough carbohydrates, unplanned physical activity, and drinking large quantities of alcohol or alcohol without food. Sometimes there just is no obvious cause. Conscious individual When the individual has symptoms that they are going into hypoglycaemic shock, immediately give g of fast-acting carbohydrate: Small glass of sugary (non-diet) drink At least three glucose tablets Five sweets, such as jelly babies Small carton of pure fruit juice Glucose gel. It is recommended that the blood glucose levels are re tested after minutes and if the blood glucose levels are still less than 4 mmol/l encourage them to eat again. Please Note Do not give foods that are high in fat such as chocolate and biscuits because the fat will delay the absorption of the glucose and won t treat the hypoglycaemia quickly enough. Unconscious individual If the individual has a severe hypoglycaemic attack and becomes unconscious; put the individual into the recovery position If prescribed and part of the diabetic care plan give a glucagon injection - some people with insulin treated diabetes are prescribed glucagon injections. Ask your diabetes healthcare team if you need one call an ambulance if a glucagon kit is not available or the individual have not recovered within ten minutes of receiving the glucagon injection if no one is trained to give a glucagon injection an ambulance should be called immediately do not give anything by mouth report and record and inform the diabetes healthcare team Referral to hospital We have in place an Individuals Passport which goes with the individual if they are admitted to hospital. This passport in checked and updated at the monthly care plan review. Liaison with the hospital team prior to subsequent discharge of an individual with diabetes is essential. Revision May / 9

9 Quality An audit of our diabetic care is included in our quality monitoring systems. These include: clinical audit, use of a minimum data set, frequency and completion of care plan review, and implementation of a diabetes care policy. We audit hospital admission rate, hypoglycaemia rate, frequency of infection, pain nutrition, and attainment of high completion rates for annual review to improve the quality of care for our individuals. Training Statement There will be opportunities for staff to attend diabetes educational events in the local community following liaison with the community diabetes team. It has a structured curriculum that is theory driven, evidence based and resource effective, has supporting materials, and is written down. Access to other educational and training resources such as DVDs, will also be made available to all staff. They will receive regular updates. It is evidence based, to meet the needs of the resident and staff member. It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self-manage diabetes. Training outcomes are reviewed and staff competencies assessed Further Guidance NICE Guidelines and Quality Statements give guidance for both health and social care in relation to the support of people with diabetes. NICE guidelines [NG17] published August 2015 Type 1 diabetes in adults: diagnosis and management NICE guidelines [NG18] Published date: August 2015 (type 1 and type 2) in children and young people: diagnosis and management NICE guidelines [NG19] Published date: August 2015 Diabetic foot problems: prevention and management NICE quality standard [QS6] updated August 2015 in adults This policy will be reviewed annually by a registered nurse. Revision May / 9