Issue Date
December 2015 / Issue No
2
Page 1 of 13
Management of Diabetes Care
This summarises the nature, cause, effect, management and treatment of individuals with a medical diagnosis of Diabetes Mellitus. These guidelines should be read in conjunction with all other Care Practice guidelines.
Introduction
The aim of these guidelines is to provide information about diagnosis, continuing support, management and appropriate referral of residents who have diabetes.
Complications associated with diabetes can shorten life and reduce its quality.
Common complications being:-
- Heart attack and stroke [cardiovascular disease] which can be reduced by treating high blood pressure [hypertension], stopping smoking and having a healthy diet
- Kidney damage [nephropathy] eye disease [retinopathy] and foot problems which can be prevented by keeping blood glucose levels as near to normal as possible.
Where prevention fails, effective treatment can be given for foot problems, eye problems and kidney problems if they are detected early.
These guidelines apply only to the care and treatment of Diabetes Mellitus
What is Diabetes?
Diabetes Mellitus is a condition in which the amount of glucose in the blood is too high because the body is unable to utilise glucose efficiently. Glucose comes from the digestion of starchy foods such as bread, potatoes or rice, and from sugar and other sweet foods. It is also produced by the liver and passes straight into the blood stream.
To utilise glucose efficiently, it is necessary for the body to produce an appropriate level of Insulin.
Insulin is a hormone produced by the pancreas. It helps glucose to enter the cells where it is used as a fuel by the body, to produce energy. When there is a lack, or absence, of insulin the glucose builds up in the blood.
Symptoms of Diabetes
The main symptoms of untreated diabetes are:
- Increased thirst
- Passing large amounts of urine or otherwise unexplained urinary incontinence
- Extreme tiredness
- Blurred vision
- Weight loss
- Itching of the genitals
- Recurrent infections
- Wounds failing to heal
Often, however, there are no symptoms and so it is good practice to screen elderly residents for diabetes, at regular intervals.
Types of Diabetes
The most common types of diabetes are:
Type 1 diabetes:
This develops when there is a severe lack or absence of insulin in the body. This happens when the cells which produce insulin have been severely damaged or destroyed. People with this type of diabetes tend to be thin and younger when first diagnosed. They are treated with insulin injection and diet.
Type 2 diabetes:
This develops when the body can still produce some insulin but insufficient for its needs, or when the insulin produced cannot be utilised efficiently. People with this type of diabetes are often older and overweight when first diagnosed. This type of diabetes is treated by diet, exercise and tablets. Occasionally it may also be necessary to treat type 2 diabetes with insulin injection.
Type 2 diabetes is progressive and treatment will need to be monitored regularly and revised as necessary.
If left untreated or treated inadequately, diabetes can create complications such as damage to the large and small blood vessels, the nerve endings, eyes, kidneys and feet. People with diabetes also have a higher incidence of heart disease, problems with their circulation, leg ulceration and general tissue viability, for which they often require additional treatment.
People with diabetes need regular care and support to enable them to achieve and maintain the best possible level of health.
Diabetes care must meet the following requirements
Compliance with the Medication Management Policy
When a resident with diabetes does not wish to receive this care, it must be documented in their care plan, in consultation with the resident, their family and other carers and health professionals. This must include an appropriate risk assessment, done in conjunction with an assessment of mental capacity and ‘best interest’, in accordance with the Mental Capacity Act 2000.
Where service users are capable of giving or withholding consent, no assistance with medication should be given without their documented agreement. For that agreement to be effective, the service users must have received information from the prescriber at the time the medication was prescribed, about the nature, purpose, associated risks and alternatives to the proposed medication.
In an emergency situation, the existing consent or ‘best interest’ decision for the administration of a prescribed medication will apply. Where it may not be possible to document consent at the time, this must still be obtained and recorded as soon as possible, including the rationale for actions taken to manage the emergency safely and effectively.
Where a service user is capable of giving or withholding consent, no covert administration of medication is permitted. In such situations, if consent is withheld staff must not administer medication. If non Hampshire County Council employed health care practitioners work outside of this statement they will be deemed to have taken full responsibility for their actions in that administration.
Prior to providing assistance with prompting or administering medication, staff must have the written consent of the service user. In circumstances where a service user is physically unable to sign the consent form, they may verbally authorise another person to sign on their behalf. The consent form must reflect that the person signing is doing so on behalf of the service user and under their direction. This must be witnessed by a third person. Such consent must be obtained by the care manager, following assessment of need and prior to the commencement of provision of direct care services, associated with the prompting, assisting or administration of medication.
The fact that a person is suffering from a mental disorder, as defined by the Mental Capacity Act 2008, does not mean that they lack capacity to give or withhold consent. An individual service user’s capacity to consent must be continually evaluated. Professional judgement must be exercised at all times. It should be understood that consent can be withdrawn by individuals at any time.
The service user’s written consent for assistance with administration of medication must be reviewed, as a minimum, annually as their needs change.
Giving and obtaining consent is a process and not a one-off event. Service users may change their minds and withdraw consent at any time; equally a service user’s mental capacity to consent may fluctuate. If there is any doubt, it is the responsibility of the care provider manager to check that the service user still consents to receiving assistance or administration of medication from and by the care staff. Any changes must be referred to the care manager, who in turn should discuss this with the prescribing practitioner or currently responsible physician. If there is any doubt about the person’s mental capacity, a report from a consultant psychiatrist or other medical practitioner must be obtained.
When a service user is considered incapable of providing consent, or refuses medication and is judged to lack capacity, the care provider manager must discuss this with the care manager and currently responsible physician. The terms of any advance decision must be considered, to determine whether the advance decision is valid and applicable to the administering of medication.
Disguising medication in order to save life, prevent physical or mental deterioration, or ensure an improvement in a person’s physical or mental health, cannot be taken in isolation from the recognition of the human right of that person to give consent. It may, in such situations, be necessary to administer medication covertly, but in some cases, the only proper course of action may be to seek the permission of the court to do so, in the best interest of the individual.
Where a service user is considered to be lacking capacity to give consent, or where the wishes of a mentally incapacitated service user appear to be contrary to the best interests of that person, the currently responsible physician must provide an objective assessment of the person’s needs and proposed care or treatment.
Relevant others, such as relatives, carers or care workers, authorised representatives and other members of the multi-disciplinary team, must be consulted to determine the course of action that is in the best interests of the service user.
All assessments of capacity and ‘best interest’ decisions must be undertaken and recorded in accordance with the Mental Capacity Act, and associated guidance. Outcomes must be recorded as part of the care plan and must detail the agreed action plan. Any previous instructions given by the service user must be respected and taken into consideration at this time.
The decision to administer medication covertly must not be considered routine and must be viewed only as a contingency measure. Any decision to do so must be concluded only after assessment of the care needs and best interests of the individual service user in accordance with the mental capacity act and associated guidance. It must be specific to an individual service user in order to avoid the institutional administration of medication in this manner. The care plan must be reviewed whenever medication is administered, to confirm the course of action is still appropriate, and in the best interests of that individual.
Where there is significant doubt or disagreement, the County Council may wish to make a representation to the relevant health body to make application to the Court of Protection, as a matter of good practice, to enable a judicial determination of ‘best interest’ to be made
All medication related procedures MUST be undertaken in accordance with the Medication Management Policy, and service specific guidelines.
Annual Health Screening
All diabetic residents must be screened annually for diabetes as part of the Care Plan.
When a health check takes place, the urine will be checked for glucose.
Urine tests which are positive for glucose, or any other abnormality, must be reported to the General Practitioner and documented in the resident’s care plan.
If a resident has any symptoms of diabetes, but their urine test is negative for glucose, this must also be reported to the GP.
Care Planning
Each resident with diabetes will have a Diabetes Care Plan which will be reviewed monthly or more frequently if necessary.
Each resident with diabetes will also have an annual medical review of their condition in the most appropriate location, either the G.P. surgery or in the Care home.
If necessary, an appointment will be made to attend the hospital Diabetes clinic.
The frequency of this review and necessary associated arrangements and appointments must be documented in the care plan.
In order to carry out a thorough assessment of the resident’s diabetes, the doctor will need the following information:-
DietCurrent M.U.S.T. assessment and any M.U.S.T. care plan
Monitoring results
A record of all blood and urine tests
A urine specimen in a clean bottle will usually be needed by the clinic or surgery
A blood test may have been requested by the GP 1-2 weeks prior to the review
MedicationA copy of the current Medication Administration Record sheet.
General Condition
Information about any change in resident’s medical condition since their last appointment
A Diabetes Review should consist of:
- General assessment of well being – mental and physical
- Review of diet & lifestyle issues – exercise, smoking status, influenza vaccination status
- Height, weight, BMI
- Detailed medical assessment - Blood pressure measurement – may be lying and standing
- Review of medication
- Examination of feet, legs and assessment of foot risk status.
- Waterlow or Braden Score risk assessment for tissue viability
- Visual acuity and fundoscopy (eye sight test and examination of the back of the eye) where possible, in certain situations sedation may be required to achieve this
- Assessment of blood glucose control – discussion, blood test and records - incidences of hypoglycaemia (low blood glucose)
- Assessment of kidney function and cholesterol or lipids (blood and urine test)
- Completion of the annual review record
Lead Member of staff for Diabetes care
Each home will have a named member of staff, trained and accredited in the care of people with diabetes.
Training must include:
- Understanding of the types of diabetes
- Importance of blood glucose control and monitoring, including blood testing, the interpretation of results and maintenance of equipment
- How to test urine and interpret results
- Risk assessment and management issues in diabetic care
- Cultural and ethical issues involved in diabetic care
- Avoidance and management of hypo and hyperglycaemia
- Screening for complications – e.g. foot care, eye disease and cardiovascular disease
- Principles of healthy eating
- Care of multiple health issues
- Care plan development, recording, management and the annual review process
- Awareness of organizations such as Diabetes UK
Maintaining knowledge and Skills
Following training and accreditation, Diabetes Care designated staff must ensure that they maintain and update their knowledge regularly.
Diet
Dietary Guidelines
The recommendation for people with diabetes is a normal, varied, healthy diet, high in fibre and low in sugar and saturated fat. On entry to a residential care or nursing home, all individuals will be have a routine M.U.S.T. assessment, and if necessary a M.U.S.T. Care plan will be developed, with subsequent monthly reviews. Some residents may be nutritionally at risk, and where an individual is identified as being malnourished, and requiring nutritional supplement drinks or a specialised diet, a registered dietician or specialist registered nurse must be consulted for further advice.
Any M.U.S.T. care plan will be developed in consultation with the resident, their family and carers and should be acceptable to the individual, taking into consideration their likes and dislikes in order to stimulate their appetite.
A baseline M.U.S.T. assessment and BMI on admission are essential to accurate nutritional assessment. Wherever possible, residents should be encouraged to eat a varied, balanced diet.
Meals should provide a varied and nutritionally balanced diet.
Regular Eating
When residents are taking medication for diabetes, they need to eat regularly to prevent hypoglycaemia (a low blood glucose level). High fibre, starchy foods should be encouraged at each meal. Individual eating patterns and plans must be monitored and supplementary meals provided as necessary.
Carbohydrate and Fibre
Meals should always include starchy carbohydrates such as bread, potatoes and or breakfast cereals. Pasta and rice are also good sources. High fibre options, such as potatoes with skins, wholemeal and whole grain bread, wholegrain cereals should be encouraged and will also help to prevent constipation.
It is very important to maintain a good fluid balance and to drink at least 1.5 litres of fluid of choice per day. This equates approximately to 10 teacups, although cups vary in size and consequently will deliver different volumes.
Five portions of fruit, vegetables or pulses are recommended to be eaten each day.
Because of the natural sugar content, fruit needs to be spread across the day and fruit juice limited to one small glass (100 ml) at mealtimes.
Sugar
The diet does not need to be sugar-free, but where possible, high sugar foods may be replaced by low sugar alternatives, especially for overweight residents.
Small amounts of sugar do not adversely affect blood sugar when taken as part of a high fibre meal. Residents with diabetes, may occasionally eat small portions of cake or chocolate, providing this is part of a balanced, healthy diet.
The Diabetes UK booklet ‘Home Baking’ contains recipes for reduced sugar, high fibre cakes, biscuits and breads.
Fat and Obesity
Weight loss is desirable for obese residents, however, for some this may be difficult e.g. those with marked immobility when maintenance of current weight may be more realistic.
If residents are overweight, their total fat intake may be reduced to help them lose weight. Individual eating plans will be developed to include individual choice and dietary advice. Family members, friends and other carers may be involved in the development of a person centred eating plan.
Unless contraindicated by any medication or medical condition, alcohol may be taken, but should be monitored
N.B. Special ‘diabetic’ foods should be avoided, as they are usually unnecessary. They may contain substances that have a laxative effect and offer no special benefits.
Monitoring
Diabetes control can be directly assessed by testing a person’s blood glucose level from a finger prick blood sample, or indirectly by testing the urine.
The normal blood glucose level is between 4 and 7 mmol/l and in the non-diabetic individual there is usually no sugar detected on a urine test. A blood glucose monitoring record must be kept in conjunction with the Diabetes Care plan.
All monitoring equipment must meet recognised standards for infection control, quality control (accuracy) and health and safety. When staff are performing blood glucose monitoring, it should be remembered that this is an invasive procedure, and is subject to all relevant service specific and professional standards guidelines.
Only single use, disposable finger pricking lancets may be used.
Venous blood sample
This test (the HbA1c) reflects the average blood glucose control over the last 6-8 weeks and is a guide to how well an individual’s diabetes is controlled. The General Practitioner will request this test if required.
Frequency of tests
The care plan must describe the type and frequency of testing agreed for each person. This must be based on the stability of their glucose control and the need for the results to be considered for treatment changes.
Sudden changes in test results in a person who is usually stable may indicate that the resident is unwell and may have an infection. If the results do not stabilise (e.g. overnight) the doctor must be informed.
Medication
An individual’s diabetes may be controlled by diet, medication or a combination of both.
Diabetes is a chronic condition. It is expected that during a person’s life, their treatment will be reviewed and changed to maintain best possible control of blood glucose levels with optimum quality of life. A medication review should be carried out by the patient’s doctor at least annually.